
Glass _3iL&2! 
Book H^fe- 



■■^SifWS> 



PRACTICAL OBSERVATIONS 



ON 
THE TREATMENT 

or 



ULCERS ON THE LEGS. 



PRACTICAL OBSERVATIONS 



THE TREATMENT 

OF 

ULCERS ON THE LEGS, 

CONSIDERED AS 

A BRANCH OF MILITARY SURGERY. 

TO WHICH ARE ADDED, 

SOME OBSERVATIONS 

ON VARICOSE VEINS, AND PILES. 

FIRST AMERICAN EDITION. 



BY EVERARD HOME, ESQ. F.R.S. 

SURGEON TO THE ARMY AND ST. GEORGE'S HOSPITAL. 



PHILADELPHIA : 



PUBLISHED BY EDWARD PARKER, 

NO. 178, MARKET STREET. 

William Brown Printer, Church-alley. 



v^ 



vx 



TO HIS ROYAL HIGHNESS 

FREDERICK, 

DUKE OF YORK AND ALBANY, 

field marshal and commander in chief of 
his majesty's forces. 

Sir, 

JN o surgical complaint, incident to the sol- 
dier, has deprived his Majesty's service of 
so many men as that of ulcers on the legs ; it 
is therefore a disease, the effects of which 
your Royal Highness, in considering the mi- 
litary resources of the country, must always 
have seen with regret. 

From viewing the subject in this light, I 
have presumed to lay before your Royal High- 
ness the following pages ; in which an attempt 



VI DEDICATION. 

is made to diminish an evil so destructive to the 
effective strength of the army. I am the more 
encouraged to address them to your Royal 
Highness from having experienced, while un- 
der your royal Highness's command upon the 
Continent, a ready compliance with every ar- 
rangement that was suggested for the relief of 
the soldier, accompanied with an earnest soli- 
citude for his welfare. 

A great part of my experience on this sub- 
ject, has been acquired in Military hospitals, 
and I now communicate my observations to 
the Public, from a desire to be of use in this 
the most common and necessary branch of Mi- 
litary Surgery. 

The present work, I hope, will not be con- 
sidered as unworthy of your Royal Highness's 
protection, the honourable sanction of whose 
name will show, that whatever may be its im- 
perfections, the subject of it has attracted the 
notice of your Royal Highness, and therefore is 
highly deserving of the consideration of the 
General and Field Officers of the Army. 



DEDICATION. Vll 

The support it may receive from the Com- 
manding Officers of Regiments, excited by 
your Royal Highness's example, will also be 
the means of its engaging the study and atten- 
tion of every military surgeon. 

I have the honour to be, 
with the greatest respect, 
Sir, 
your Royal Highness's devoted 
and most obedient 

humble servant 

EVERARD HOME. 



TABLE OF CONTENTS. 



Pag* 

Introduction 13 

CHAPTER I. 
On the properties of Pus 25 

CHAPTER II. 

General observations on ulcers on the legs 54 
General distribution of ulcers into their 

species - 65 

CHAPTER III. 

Of ulcers in parts which have sufficient 
strength to carry on the actions necessa- 
ry for their own recovery 68 

applications considered with reference to 
this species of ulcer 72 

CHAPTER IV. 

Of ulcers in parts that are too weak to car- 



X TABLE OF CONTENTS. 

Page 

ry on the actions necessary for their own 
recovery ... 76 

Applications considered^ with reference to 
this species of ulcer - 86 

CHAPTER V. 

Of ulcers in .parts whose actions are too 
violent to form healthy granulations ; 
whether this arises from the state of the 
parts or of the constitution - 95 

Applications considered^ with reference to 
this species of ulcer - - 106 

CHAPTER VI. 

Experiments and observations on the irri- 
tability of nerves, by which the spasmo- 
dic affections attendant upon irritable 
ulcers are accounted for - 121 

CHAPTER VII. 

Of ulcers in parts whose actions are too 
indolent to form healthy granulations^ 
whether this indolence arises from the 
state of the parts or of the constitution 158 

Applications considered^ with reference to 
this species of ulcer - - 167 



TABLE OP CONTENTS. . XI 

CHAPTER VIII. 

Page 

Of ulcers attended with some specific dis- 
eased action, whether constitutional or 
local 200 

1. Of those ulcers which yield to mercury 203 

2. Of ulcers which yield to the use of dif- 
ferent preparations of the conium macu- 

latum, or hemlock - - - 206 

3. Of Ulcers which yield to the application 

of salt water - - 209 

4. Of ulcers which yield to the use of the 
argentum nitratum - - 211 

5. Of ulcers which yield to the use of arse- 
nic - ♦ 218 

CHAPTER IX. 

Of ulcers attended with a varicose state of 
the veins of the limb, and the advantages 
derived in such cases from including the 
vena saphena in a ligature - - 223 

Cases of the vena saphena included in a 
ligature , to promote the cure of ulcers on 
the leg 245 



XU TABLE OF CONTENTS. 

CHAPTER X. 

Page 

The effects of ligatures on varicose veins 
in cases of enlarged vena saphena, varu 
cocele 9 and piles - - - 272 

On tying the vena saphena to render it 
less varicose. - - 273 

On tying the spermatic vein in cases of 
varicocele . . . 282 

On tying piles so as to prevent the painful 
symptoms usually produced by that ope* 
ration . . - 290 



INTRODUCTION. 



WHEN we consider the number of re« 
emits who are rejected, and the number of 
well disciplined men who are discharged from 
the army on account of ulcers on the legs, 
it must appear to be one of the most impor- 
tant duties of every military surgeon, to pay 
particular attention to a complaint, which ren- 
ders so many men unfit to perform the duties 
of soldiers. 

It has been unpropitious to the improve- 
ment of the treatment of ulcers on the legs, 
that they have been universally admitted to 
be the most unmanageable cases which be- 
come the objects of surgery ; that they are 

B 



XIV INTRODUCTION. 

cases in which the most eminent surgeons 
are two often known to fail in performing a 
cure ; and, therefore, bring no imputation of 
want of skill upon those practitioners who 
happen to prove unsuccessful. 

This has led the younger part of the pro- 
fession in the army to be too diffident of their 
own abilities ; to despair of success where so 
many have failed; and to follow a beaten 
track, in which so little advance has been 
made, that ulcers on the legs are not unjustly 
considered as the opprobrium of surgery. 

Ulcers on the legs when regiments are em- 
ployed on service, are too frequently conceal- 
ed, and consequently neglected, till they have 
increased to a considerable size ; and this, 
fair many instances, happens from a desire in 
the soldier to avoid his duty, or to procure 
his discharge. In this way, too many men 
have been finally lost to the army. When- 
ever this kind of imposition succeeds, it is 
productive of much greater mischief than the 
loss of the individual to the service, by in- 



INTRODUCTION. XV 

ducing other men, when dissatisfied, to make 
similar attempts, which otherwise would not 
have been suggested to their minds. It is' 
therefore adviseable, whenever there is the 
smallest suspicion that any men have hurt 
their legs from such motives, to keep them 
in the regiment, even when rendered unfit 
for duty. 

If the idea that this disease is incurable, 
prevails in a regiment, the soldiers will be 
very ready to take advantage of such an opi- 
nion ; and the surgeon who admits of it, will 
not be induced to give cases of this kind the 
degree of attention which is necessary to per- 
form a cure, or to detect those men who are 
artfully counteracting his endeavours. 

As the difficulty in effecting a cure, applies 
only to those ulcers which have increased to 
a considerable size, or have been long in a 
bad state ; there should be a regulation in all 
regiments, that the smallest ulcers on the legs 
are to be immediately reported to the sur- 
geon; the non-commissioned officers of every. 



XVI INTRODUCTION. 

company should be required to enforce this 
regulation ; and all men so reported, should 
remain under the direction of the surgeon 
till perfectly recovered. 

A regulation of this kind would be the 
means of saving many good men to the ser- 
vice, and preventing many others from leav- 
ing it ; as ulcers on the legs, in their early 
stages, admit of being healed even by sur- 
geons whose attention has not been particu- 
larly directed to the subject. 

There is in many regiments, an unwilling- 
ness in the commanding officers in compa- 
nies to have their men put into the regimen- 
tal hospital for slight complaints ; and those 
men who are not removed from their barracks, 
are so little under the controul of the sur- 
geon, that he does not feel them intrusted to 
his charge ; they are, therefore, of course ne- 
glected both by themselves and the surgeon. 
This is perfectly well known to be true ; and 
in many slight cases of disease may be pro- 
ductive of no material harm ; but since it is 



INTRODUCTION. XV11 

generally allowed, that ulcers on the leg are 
so little in the power of the surgeon when they 
arrive at a bad state, the commanding officers 
of regiments should put it into orders, that 
every man affected with such a complaint,, is 
'to be placed under the sole management of 
the surgeon ; that the evil may be encoun- 
tered in time, and the patients have a chance 
of being recovered. 

Men who have been cured, and return to 
their duty, should be made to wear a bandage 
and compress for some time, as a support to 
the newly formed parts, and a defence against 
accidental violence. A piece of thin tea lead 
may be used with advantage for this pur- 
pose. 

If ulcers on the leg, when neglected, are 
found in the country, to spread and become 
a very serious disease, it happens in a still 
greater degree in the West Indies, where the 
slightest previous hurt upon the Icg^ or a 
small ulcer, will, from the effects of fatigue 
in that climate, in a very short time, become 
b 2 



XVM INTRODUCTION. 

an ulcer of the worst description, and render 
the patient entirely unfit for service. Too 
much attention, therefore, cannot be paid to 
the conduct of the soldier in hot countries, to 
prevent ulcers ; and when they occur, to put 
the men as soon as possible under the direc- 
tion of the surgeon. 

At St. Lucia, during the American war, I 
had several conversations upon this subject 
with Dr. Young, physician to the army ; who 
had been formerly a regimental surgeon, and 
had served in the Windward Islands in the 
year 1765, and the three following years. In 
that period he had made some remarks, which 
led him to conclude, that tall men are less 
able to bear the climate of the West Indies, 
and are more liable to ulcers on the legs than 
others. As his observations are curious, they 
are laid before the reader. 

Dr. Young observed, that in the 32d re- 
giment, there were 145 tall men, and 276 
short men. That In the course of four years 
29 were discharged from those of the first 



rNTRODUCTION", XIX 

description, and only 23 from die second, on 
account of ulcers on the legs. The ulcers 
were of such a nature as to be deemed incura- 
ble in that climate. Some of the patients 
were obliged to undergo amputation, to give 
them a chance for their lives ; others had so 
many of the muscles and tendons injured as 
to render them, ever after, unfit for service, 
The principal cause why tall men are more 
subject to ulcers on the legs than short men, 
Dr. Young conceived to be the length of the 
column of blood in their veins ; which, by its 
pressure, renders the legs less able to recover 
when hurt by any violence. He observed, at 
the same time, that tall men are less able to 
support the heat of the climate ; and by losing 
their general health, are rendered more liable 
to have ulcers on the legs. From these re- 
marks Dr. Young concludes, that many lives 
might be saved, by omitting to send any 
grenadier companies to the West Indies. 

After having made these observations on 
the 32d regiment, Dr. Young went upon the 
expedition against Martinique and the Havar>~ 



XX INTRODUCTION. 

na ; and was surprised to find that ulcers on 
the leg, in another regiment, were less fre- 
quent, although the mode of life, diet, and all 
general circumstances were the same, and the 
fatigue considerably greater* This he was led 
in some measure to attribute to the circum- 
stance of the men wearing half boots of cloth, 
which defended the legs from many slight 
accidents occasioned by marching through 
uncleared paths, by kicks, or the bites of 
musquitoes. They also kept the legs dry ; 
and gave a support to the veins, which wool- 
len cloth gaiters, from their elasticity, will do 
in a greater degree than those made of leather 
and linen. * 

The mode of treating ulcers on the legs in. 
regimental, and other military hospitals, I 
have had many opportunities of seeing, while 
employed as an army surgeon ; and have made 
particular inquiries from those who are at 



* Dr. Young did not mention whether the grenadiers were 
more liable to a varicose state of the veins of the legs, but his 
observations certainly imply that they were* 



INTRODUCTION- XXI 

present surgeons of regiments, and find it to 
be still the same. They are commonly all 
treated upon one general plan. If the ulcers 
are in a foul state, they are poulticed ; when 
they become clean, they are dressed. The 
same kind of poultice is used to all foul ulcers, 
and the same kind of dressing is used to all 
those which put on a more favourable ap- 
pearance. If a new mode of treatment for 
ulcers is at any time published by a surgeon 
whose character is respectable, this is tried. 
The result, in general, is, that in some cases 
it is found to answer ; in many others it fails ; 
and, upon the whole, usually falls short of the 
expectations that had been raised. It is 
therefore very soon thrown aside ; and the 
old plan, though allowed by every surgeon 
individually to be bad, is resumed. 

Such must of course, continue to be the 
case, while the disease remains uninvestigated ; 
and the different species of ulcers, and their 
varieties arising from natural peculiarities, are 
not understood. Since, without such know- 
ledge, all trials of different applications be- 



XX11 INTRODUCTION. 

come so many random experiments, which, 
by their too frequent failure, will discourage 
the practitioner from prosecuting so fruitless 
an inquiry. With a view to enlarge our 
knowledge, and to establish some general prin- 
ciples, that may guide us in the treatment of 
ulcers on the legs, an attempt is made to ar- 
range them under different heads, and to point 
out those distinguishing characters of each 
species, which will make one mode of treat- 
ment more likely to produce a cure than 
others of a different kind ; giving an account 
of those local applications of which I have 
had experience, and their particular effects. 

By these means it is hoped, in some mea- 
sure, to clear the way for those who may be 
led hereafter to take up this subject ; and that 
an arrangement having once been made, under 
which the observations and detached facts 
noticed by individuals may be collected in a 
small compass, the treatment of ulcers on the 
legs may in process of time be very much 
improved ; and many cases of that kind cured, 



INTRODUCTION. XX111 

which at present are considered as beyond 
the reach of surgery. 

A plan of this kind will be favourably re- 
ceived by the surgeons of the army, who have 
so many cases of this kind intrusted to their 
care. It will shew them the extent of the 
inquiry, and that very fittle has hitherto been 
done. It will point out also, how much it 
is in the power of every individual to add to 
the stock of our knowledge, and thereby ad- 
vance his own credit and the public benefit, 



CHAPTER I. 

ON THE PROPERTIES OF PUS.* 

IN considering the properties of Pus, and 
its effects upon the body, it is not intended to enter 
minutely into the opinions of either the ancient or 
modern authors respecting it ; or to examine the 
arguments by which these opinions have been sup- 
ported; but to endeavour, by experiments and 
observations, to investigate the different parts of the 
subject. 

It may not, however, be improper to take 
notice, that the most generally established opinion 
of the nature of Pus, till within the last thirty 
years, has been, that it was composed of both 
solids and fluids ; nor is the opinion, even now, 
entirely exploded. It was called, " true, or laudable 
Pus ;" to distinguish it from a similar discharge, 

* The following observations made part of a prize dissertation 
printed in the year 1788, by order of the Lyceum Medicuir* 
Londinense.* 



26 ON THE PROPERTIES OF PUS. 

supposed to be composed wholly of fluids, called 
Mucus. Yet the distinctions between Pus and 
Mucus have been veryall defined : there was thought 
to be a difference, in their appearance to the eye ; 
but the principal mark of distinction arose from 
a breach of surface being believed necessary to the 
formation of Pus, but not of Mucus ; consequently, 
when there was no breach in the solids, the dis- 
charge was considered to be only Mucus. 

This notion of Pus must have taken its rise from 
an idea that the solids of the part were broken down 
i»to Pus. The physiologists, who formed this 
theory, cannot, however, be said to have made their 
distinctions with great accuracy, since the discharge, 
in consequence of a blister being applied to the 
surface of the body, was admitted to be Pus ; 
although in such cases there is no loss of substance, 
and therefore the discharge should have been called 
Mucus. 

To ascertain a real difference between the fluid 
formed where there is a breach in the solids, and that 
met with where the surface is entire, has been 
considered an object meriting the attention of some 
of our most eminent surgeons, although the fluid 
formed under both these circumstances will be 
found to be precisely the same. This inquiry must 



ON THE PROPERTIES OF PUS. 27 

Have arisen from their adhering to the hypothesis 
which has been mentioned ; and which, not being 
founded upon the principles of the animal oeconomy, 
can never explain, satisfactorily, any of the opera- 
tions in the living body. 

It will be found upon investigation, that the ap- 
pearance of a discharge produced from the secreting 
surface of an internal canal, or excretory duct, when 
the produce of the suppurative inflammation is 
exactly similar to a discharge, in consequence of 
inflammation, in any other part of the body. The 
only respect in which they differ is, that in the one 
case there is no breach of surface, and in the other, 
there most commonly appears to be one. The one 
is suppuration alone ; the other, suppuration at- 
tended by ulceration. 

It is intended in the present inquiry ; to collect 
those properties and circumstances which have 
been ascertained respecting Pus ; and to endeavour, 
by investigating others not so well understood, to 
render the history of it more complete. 

Through the whole of these observations, Pus 
will be considered as a fluid, whose formation 
depends upon a process in the animal ceconomy, 
analogous to glandular secretions, 



28 ON THE PROPERTIES OF PUS. 

It is difficult to give a definition of any thing, the 
properties of which are not well ascertained ; but as 
it is necessary to particularize the substance which 
it is proposed to investigate under the term Pus, it 
may be defined to be a whitish fluid, made up of 
globules, and a transparent aqueous liquor. Its 
production depends upon inflammation having 
previously taken place in some part of the body, 
either in the common reticular membrane, upon the 
internal surface of circumscribed cavities, or the 
surfaces of internal canals, which form excretory 
ducts of the body. 

Inflammation is necessary for the formation of 
Pus ; and although a fluid, some-what similar, - 
is produced without any preceding inflammation, such 
fluid, not having all the properties of true Pus, 
can be readily distinguished from it. 

Pus, whether it is formed in the cellular mem- 
brane, upon an investing membrane, or on the in- 
ternal surface of an excretory duct, has exactly the 
same appearance, and general properties : no dis- 
tinctions will therefore be made between Pus pro- 
duced under this or that peculiar circumstance, be- 
lieving it, when preceded by the same degree of 
inflammation in a healthy constitution, and when free 
from any extraneous substances, to be the same 
fluid ; but as a difference in Pus mav arise from a 



ON THE PROPERTIES OF PUS. 29 

variety of causes, it will be proper first to mark 
those properties which really belong to it in a heal- 
thy state of body ; and afterwards mention the 
variations to which it is liable. 

Pus, taken from a healthy ulcer near the source 
of the circulation, as on the arm or breast, readily 
separates from the surface of the sore, the granula- 
tions underneath being small, pointed, and of a flo- 
rid red colour, and has the following properties : 
it is nearly of the consistence of cream ; is of a 
white colour ; has a mawkish taste ; and when 
cold, is inodorous ; but when warm, has a peculiar 
smell. Examined in the microscope, it is found 
to consist of two parts, of globules, and a transpa- 
rent colourless fluid ; the globules are, probably, 
white, at least they appear to have some degree of 
opacity : its specific gravity is greater than that of 
water : it does not readily go into putrefaction : 
exposed to heat, it evaporates to dryness ; but does 
not coagulate : it does not unite with water in the 
heat of the atmosphere, but falls to the bottom ; 
yet, if kept in a considerable degree of heat, rises, 
and diffuses through the water, and remains mixed 
with it, even after having been allowed to cool ; 
the globules being decomposed. 

Pus varies in its appearance, according to the 

different circumstances which affect the ulcer that 
c 2 



30 ON THE PROPERTIES OF PUS. 

forms it, such as the degree of violence of the in- 
flammation ; also its nature, whether healthy or 
unhealthy ; and these depend upon the state of 
health and strength of the parts yielding Pus. 

These changes arise more from indolence, and ir- 
ritability, than from any absolute disease : many 
specific diseases, in healthy constitutions, produ- 
cing no change in the appearance of the matter 
from their specific quality. Thus the matter 
from a gonorrhoea, from the small-pox pustules, the 
chicken-pock, and from a healthy ulcer, has the 
same appearance, and seems to be made up of 
similar parts, consisting of globules floating in a 
transparent fluid, like common Pus, the specific 
properties of each of these poisons being super- 
added to those of Pus. Matter from a cancer 
may be considered as an exception ; but a can- 
cerous ulcer is never in a healthy state. 

In indolent ulcers, whether the indolence arises 
from the nature of the constitution, weakness of 
the parts, or the nature of the inflammation, the 
Pus is made up of globules, and flaky particles 
floating in a transparent fluid ; and these globules 
and flakes are in different proportions, according 
to the degree of indolence : this is particularly 
observable in scrofulous abscesses, preceded by a 
small degree of inflammation. That this flaky ap- 



ON THE PROPERTIES OF PUS. 31 

pearance is no part of true Pus is well illustrated, 
by observing, that the proportion it bears to the 
globules is greatest where there is the least inflam- 
mation ; and in those abscesses that sometimes oc- 
cur, which have not been preceded by any inflam- 
mation at all, the contents are wholly made up of 
a curdly or flaky substance, of different degrees 
of consistence, which i» not considered to be Pus, 
from its not having the properties stated in the de- 
finition of that fluid. 

The constitution and part must be in health to 
form good Pus ; for very slight changes in the 
general health are capable of producing an alteration 
in it, and even of preventing its being formed at all, 
and substituting in its place coagulating lymph. 
This happens most readily in ulcers on the lower 
extremities, owing to the distance of the parts from 
the source of the circulation, rendering them 
weaker. And it is curious to observe the in- 
fluence, that distance alone from the heart has upon 
the appearance of Pus. 

A man had a compound fracture of the right leg, 
and an ulcer on the ankle of the left ; he was in 
tolerable health, both the ulcers looking well. An 
attack of fever came on soon after, when the ulcer 
on the ankle ceased to form good Pus, the matter 



32 ON THE PRORPETIES OF PUS. 

not separating readily from its surface, while the 
compound fracture continued to look very well ; 
but in twelve hours more, the same change had 
taken place in the opening of the compound frac- 
ture, which was about six inches higher up the leg 
than the ulcer. 

In irritable ulcers, the discharge is often thin, 
being principally made up of an aqueous fluid pos- 
sessed of an irritating quality, and containing few 
globules ; such ulcers are commonly attended with 
hemorrhage from the smaller vessels, by which 
means the discharge is very materially altered in 
its properties, is rendered acrid, and more ready to 
run into putrefaction than true Pus. We find, 
however, in many irritable constitutions, the same 
appearances that were mentioned to take place in 
the indolent, the coagulating lymph being thrown 
out, and adhering firmly to the surface of the ulcer ; 
therefore the appearance of an ulcer alone will not 
lead us to a correct judgment of its nature, but 
will only inform us whether it is healthy or unheal- 
thy. 

Although these different appearances of Pus have 
been noticed, from their being so connected with its 
history as to deserve attention, they are not to be 
considered as belonging to true Pus ; but as arising 



ON THE PROPERTIES OF PUS 33 

from a defect in the process, whatever it is, by 
which Pus is formed. 

As Pus has been supposed to have a corroding 
quality, the following experiments were made, to 
ascertain the truth or fallacy of such an assertion, 
and it was found to be void of foundation, and to 
have arisen from an inaccuracy, whichjprevented 
observers from seeing the distinctions between Pus 
in a pure state, and when mixed with other 
substances. 



EXPERIMENT I. 

A comparative trial was made upon the Pus 
contained in an abscess, and on Pus, and animal 
jelly out of the body. The matter and jelly were 
in equal quantities, and contained in glass vessels 
kept nearly in the temperature of the human body. 
To make the comparative trials as fair as possible, 
a portion of muscle, weighing exactly one drachm, 
was immersed in the matter of a compound fracture, 
in the arm of a living man, and a similar portion 
into some of the same matter out of the body ; also 
a third portion into fluid calf's foot jelly, in which 



34 ON THE PROPERTIES OF PITS. 

\he animal substance was pure, having neither wine 
nor vegetables mixed with it. These three portions 
of muscle were taken out once every twenty-four 
hours, washed in water, weighed, and returned, 
again. The results were as follows : 

In 24 hours — the portion of muscle in the ab- 
scess weighed sixty grains, was pulpy and soft, but 
quite free from putrefaction : that portion immers- 
ed in the Pus weighed forty-six grains, was pulpy, 
soft, and had a slightly putrid smell : the portion in 
the jelly weighed thirty-eight grains, was smaller, 
and firmer in its texture. 

In 48 hours— the portion of muscle in the ab- 
scess weighed thirty-eight grains, and had under- 
gone no change : that in the matter weighed thirty- 
six grains, was softer, and more putrid : that in the 
jelly thirty-six grains, and smaller. 

In 72 hours — the portion of muscle in the abscess 
weighed twenty-seven grains, was drier, and firmer: 
that in the matter eighteen grains, and was rendered 
fibrous and thready : that in the jelly unaltered. 

In 96 hours — the portion of muscle in the abscess 
weighed twenty-five grains : that in the matter was 



ON THE PROPERTIES OF PUS. 35 

dissolved : that in the jelly weighed thirty-six 
grains. 

In 120 hours — the portion of muscle in the ab- 
scess weighed twenty-two grains, not at all putrid : 
that in the jelly thirty-four grains, not at all putrid. 

In 144 hours — the portion of muscle in the ab- 
scess weighed twenty-two grains, and was free 
from putrefaction: that in the jelly thirty-four 
grains. 

The next day the jelly had evaporated to dryness, 
which put an end to the comparative experiment* 
The portion of muscle in the abscess was kept there 
a few days longer, without undergoing any change 
or diminution of weight ; and was taken out in con- 
sequence of the arm requiring fomentation, which 
interfered with the experiment. 



EXPERIMENT II. 

A similar experiment was made upon the matter 
contained in an abscess recently opened, where the 
Pus was not pure, but mixed with blood from the 



36 Otf THE PROPERTIES OF PUS* 

cut edges of the external opening, which had not 
come to suppuration. 

A portion of recent muscle, weighing one drachm, 
was immersed in the abscess ; and a similar por- 
tion in a small vessel of water, of nearly the tem- 
perature of the human body. 

In 24 hours — the portion of muscle in the ab- 
scess weighed twenty-four grains, and was very 
putrid : that in the water forty grains, rendered 
smaller, but free from putrefaction. 

In 48 hours — the portion of muscle in the abscess 
was wholly dissolved : that in the water weighed 
thirty-eight grains. 

This circumstance alone of Pus, when in a pure 
state, not readily taking on the putrefactive fermen- 
tation, distinguishes it from those fluids which are 
not perfect, but a mixture, which Pus must be rec- 
koned, in these instances, where it has extraneous 
parts mixed with it ; and likewise distinguishes it 
from the produce of fermentation of animal or ve- 
getable substances, as they run very readily through 
all the different stages of fermentation, that process 
being once begun. 



ON THE PROPERTIES OF PITS. 37 

The property which characterizes Pus, and dis- 
tinguishes it from most other substances, is, its 
being composed of globules. This appears to throw 
considerable light upon the subject ; since the pre- 
sence of the globules seems to depend upon the Pus 
being in a perfect state ; from which we learn the cir- 
cumstances necessary for the production of good 
Pus. Mr. Hunter was, I believe, the first who 
pointed out this property as a distinguishing mark 
between Pus and animal Mucus.* For the ap- 
pearance of what is commonly termed Mucus, that 
is, animal substance dissolved from putrefaction, is 
flaky, and very different from Pus. It is also by 
this property distinguished from all the chemical 
combinations of animal substance that we are ac- 
quainted with ; every one of which appears in the 
microscope to be made up of flakes. 

At the same time that this appearance in the mi- 
croscope distinguishes Pus from other substances, 
it shows its great affinity to the animal secretions, 

* Morgagni quotes Senac as asserting that the globules in 
the matter of gonorrhoea are much larger than those of com- 
mon Pus, which are small and unequal. The edition of Senac 
in which this is mentioned I have not seen, but in the later 
ones it is omitted, and very properly, as it was evidently ei> 
roneous. 



38 ON THE PROPERTIES OF VUS. 

although in many circumstances it differs from 
them. 



It differs from the blood in the colour of the glo- 
bules ; in their not being soluble in water, which 
those of the blood are ; and from the fluid in which 
they swim being coagulable by a solution of sal am- 
moniac, which serum is not. 



EXPERIMENT III. 

A drop of matter, and a drop of blood, were 
placed upon a piece of glass, at a small distance 
from each other, and the glass was fixed under the 
magnifyinglens of a microscope : while in this situa- 
tion, the point of a toothpick was dipped in a satu- 
rated solution of sal ammoniac, and applied to each 
of them. This was repeated two or three times. 
The drop of matter, instead of appearing more di- 
luted, became viscid and ropy ; and upon being ex- 
amined through the magnifying glass, the globules 
appeared perfectly distinct in the coagulum. 

The drop of blood had no appearance of coagula- 
tion ; on the contrary, it was more diluted. 



ON THE PROPERTIES OP PUS. 39 

This experiment was repeated several times, and 
the results were always similar. 

Pus differs from chyle, in its globules being 
larger ; not coagulating by exposure to the air, nor 
by heat, which those of chyle do . 

The pancreatic juice contains globules; but they 
are much smaller than those of Pus. 

Milk is composed of globules, nearly of the same 
size as those of Pus ; but much more numerous. 
Milk coagulates by runnet ; which Pus does not ; 
and contains oil and sugar, which are not to be dis- 
covered in Pus. 

The cases in which Pus is formed are, properly 
speaking, all reducible to one, which is, the state of 
parts consequent to inflammation. For, as far as we 
yet know, Pus has, in no instance, been met with, 
unless preceded by inflammation ; and although in 
some cases a fluid has been formed, independent of 
preceding inflammation, it differs from Pus in many 
of its properties, as has been already observed. 

In inflammation, the smaller blood-vessels be 
come considerably enlarged ; and, what is curious,, 
this takes place in the greatest degree in the veins ; 



4d 



ON THE PROPERTIES OF PUS'. 



the small vessels are not only enlarged, but become 
more numerous ; which does not proceed entirely 
from the blood being propelled further than usual 
in the old vessels, but from new ones being formed ; 
and this takes place in a much shorter time than 
has been commonly imagined. It is highly proba- 
ble, that these new vessels are so constructed, as to 
make the blood undergo certain changes, by which 
the fluid, that afterwards constitutes Pus, is formed. 

It has been long ascertained, that new vessels 
are generated in extravasated coagula of blood, and 
exudations of coagulating lymph. The following 
case ascertains the period in which this effect can 
be produced, to be within twenty-four hours. And 
we know that Pus commonly requires a much 
longer time for its formation under the same cir- 
cumstances, and in similar parts. 

I performed the operation for the strangulated 
hernia, upon a man, in other respects in health, at 
seven o'clock in the morning. The hernial sac 
was laid open, and the gut, which proved to be a 
portion of the ilium, about six inches in length, was 
attentively examined previous to its being returned 
into the cavity of the belly: it had the natural polish- 
ed surface peculiar to an intestine ; arid although 
its vessels were turgid with blood ? it did not appear 



ON THE PROPERTIES OF PUS* 41 

that they were uncommonly numerous. After the 
operation, the symptoms did not abate so much as 
might have been expected ; and, during the after- 
noon, he complained of pain in the lower part of 
his belly : he had no passage by stool ; and next 
morning, about seven o'clock, his pulse was scarce- 
ly perceptible to the touch ; his skin cold and clam- 
my ; and about twelve at noon he died, having lived 
twenty-nine hours after the operation. 

The body was opened, and the portion of gut 
which had been strangulated was found considera- 
bly inflamed ; the external surface having lost its 
natural polish, and having several small portions of 
exuded coagulating lymph adhering to it. The 
vessels of the gut were minutely injected, the arte- 
ries with a red coloured injection, and the veins 
with a yellow one. Upon examination,, afterwards, 
all these adhering portions of coagulating lymph 
were found to be injected, having a considerable ar- 
tery going to each of them, and a returning vein, 
which was larger than the artery. It is evident^ . 
therefore, that the coagulating lymph was laid upon 
the external surface of the gut after the operation : 
and we cannot suppose, that any such process as the- 
forming of new vessels could have been going on 
during the last five hours of his life, when the pulse . 

in the wrist was scarcely to be felt, and the powers 
D 2 



42 GN THE PROPERTIES OF PUS. 

of life were so much weakened in every respect. 
We must therefore conclude, that the whole opera- 
tion of throwing out coagulating lymph, and sup- 
plying it with blood vessels after it had become solid, 
was effected in less than twenty-four hours. 

This shows, that inflammation forms a vascular 
surface previous to the formation of Pus. Is it 
not, therefore, highly probable, that the newly for- 
med parts are so organized as to secrete that fluid. 

In considering the time required for the forma- 
tion of Pus, it is necessary to take notice of the 
periods which are found, under different circum- 
stances, to intervene between a healthy or natural 
state of the parts, and the presence of that fluid, 
after the application of some irritating substance 
to the skin. 

In cases of wounds made into muscular parts, 
where blood vessels are divided, the first process 
which takes, is the extravasation of red blood ; the 
second, is the exudation of coagulating lymph, 
which afterwards becomes vascular ; and the third, 
the formation of matter, which last does not, in 
common, take place in less than two days : the 
precise time will, however, vary exceedingly, ac- 



OS THE PROPERTIES OF PUS. 43 

cording to the nature of the constitution, and the 
state of the parts at the time. 

If an irritating substance is applied to a cuticu- 
lar surface, upon which it raises a blister, Pus will 
be formed in about twenty hours, as we find in the 
following experiment. 



EXPERIMENT IV- 

A blistering plaster, the size of a half-crowa 
piece, was applied to the pit of the stomach of a 
healthy young man. In eight hours a blister rose, 
which was opened, and the contents removed j 
they were fluid, transparent, and coagulated by 
heat ; had no appearance of globules when exa- 
mined by the microscope ; and in every respect 
resembled the serum of the blood. The cuticle 
was not removed ; but allowed to collapse ; and 
the fluid, which was formed upon the surface of 
the cutis, w r as examined from time to time, by a 
microscope, to detect, as accurately as possible, 
the changes which took place. The better to do 
this, as the quantity in the intervals stated below 
must be exceedingly small, a piece of talc, very 
thin and transparent, w r as applied to the whole 



44 ON THE PROPERTIES OF PITS* 

surface, and covered with an adhesive plaster ; 
and the surface of the talc, applied to the skin, was 
removed and examined by the microscope, apply- 
ing a fresh piece of talc, after every examination, 
to prevent any mistake which might have arisen 
from the surface not being quite clean. 

The fluid was examined by the microscope, to 
ascertain its appearance ; but as the aqueous part 
in which the globules of Pus swim is found, by 
experiment, to coagulate, by adding to it a satura- 
ted solution of sal ammoniac, which is not the case 
with the serum of the blood, nor the transparent 
part of milk, this was considered as a property 
peculiar to Pus ; and, consequently, that it would 
be a very good test by which to ascertain the pre- 
sence of true Pus. 

In 8 hours — from the time the blister was ap- 
plied, the fluid discharged was perfectly transpa- 
rent, and did not coagulate with the solution of 
sal ammoniac. 



In 9 hours — the discharge was less transparent ; 
it free from the appearance of globules 



but 



In 10 hours — the discharge contained globules? 
-which were very small, and few in number* 



ON THE PROPERTIES OF PUS. 45 

In 11 hours — the globules were numerous ; 
but still the fluid did not coagulate with the so- 
lution of sal ammoniac. 

In 12 hours — the appearance much the same as 
before* 

In 14 hours — the globules a little larger ; and the 
fluid appeared to be thickened by a solution of sal 
ammoniac. 

In 16 hotirs — the globules seemed to form then>> 
selves into masses , but were transparent. 

In 20 hours — the globules were double the size 
of those first observed at ten hours, and gave the 
appearance of true Pus in a diluted state ; the fluid 
was coagulated by a solution of sal ammoniac \ the 
globules, at the same time, remaining perfectly dis- 
tinct ; so that this may be considered as true Pus. 

In 22 hours — no change appeared to have taken 
place. 

In 32 hours — the fluid was considerably thicker 
in consistence, the number of globules being very 
much increased : but in no other respect, that could 



46 OS TliE PROPERTIES OF PUS. 

be observed, did it differ from that formed twenty 
hours after the application of the blister. 

As the results of microscopical experiments have 
been found exceedingly fallacious, a prejudice has 
Very naturally arisen against all experiments of this 
kind upon the secretions of the human body, from 
a supposition that they are not to be depended upon. 
But it is right that we should discriminate, and not 
condemn the use of the microscope altogether, be- 
cause, from ignorance of its principles, it has been 
misapplied ; since these very deceptions have been 
the means of our acquiring a more accurate know- 
ledge of the use and application of that instrument. 

The errors in the use of the microscope have 
arisen from increasing the magnifying powers of the 
glasses too much, and not taking in all the circum- 
stances relating to the refraction of the rays of light ; 
making no allowance for the aberration. An atten- 
tion to the aberration alone will explain the differ- 
ent appearances under which the red globules of the 
blood have been represented. Some have found 
them perfect spheres ; which will always be the case 
when the glasses are perfectly adjusted, and the ob- 
ject placed at the true focal distance. Others have 
found them annular, from the object being at the 
focal distance of the rays transmitted near the cir« 



ON THE PROPERTIES OF PUS. 47 

cumference of the magnifying glass, which are re- 
fracted in a greater degree, and consequently shorter 
than the central rays. Others again have viewed 
them as flattened bodies of a circular figure, bright 
in the centre, and becoming darker towards the 
edges; which appearance arises from the object 
being at the focal distance of the central rays of the 
magnifying glass, which will be less refracted than 
those near the circumference. Although such are 
the errors which arise when microscopical researches 
are pushed beyond certain bounds ; yet that the red 
part of the blood is made up of globules is a disco- 
very, for which we are indebted to the microscope ; 
and which seems to be as well ascertained as any 
discovery in anatomy or physiology. The appear- 
ances of Pus which have been mentioned are equal- 
ly distinct, when examined on the field of a micro- 
scope, as the globules of the blood ; they are visible 
with a small degree of magnifying power ; and are 
the same to the eyes of different persons. 

The time required to form Pus, on a secreting 
surface, appears, from the following experiments, to 
be five hours. 



48 ON THE PROPERTIES OF PUS. 

EXPERIMENT V. 

A common bougie, four inches long, was intro- 
duced into the urethra of a healthy young man. 
The surface of the bougie was not oiled, which made 
the irritation more violent, and prevented there 
being any ambiguity in the appearance of the fluid 
collected upon it. 

In I an hour — the bougie was withdrawn, and the 
fluid on its surface, examined by the microscope, 
was found to contain globules that were very small, 
and few in number, resembling those found under 
the cuticle in the blister at ten hours. The bougie 
was again introduced. 

In 1 hour — the fluid had the same appearance. 

In 1 hour and \ — the globules larger and more 
numerous. 

In 3 hours — the globules more numerous. 

In 4 hours — the globules larger; but the fluid 
did not coagulate with the solution of sal ammoniac. 



CM THE PROPERTIES OF PttS. 49 

In 5 hours — the globules large and numerous : 
the fluid coagulated with the solution of sal am- 
moniac. This was therefore considered as true 
Pus. 

To prosecute this inquiry still further, an attempt 
was made to ascertain the changes this fluid under- 
goes from the time of its leaving the extremities of 
the vessels which form it, till it becomes that thick 
fluid we find upon suppurating surfaces, called 
Pus. 

The experiments were made upon a. healthy gra- 
nulating ulcer, on the upper surface of the prepuce 
of a healthy young man, about two inches square, 
forming good Pus. 



EXPERIMENT VI. 

The surface of the ulcer was exposed; wiped 
dry, and a piece of talc applied upon one part of it, 
leaving the rest exposed. The surface of the talc 
was almost immediately covered with a thin fluid. 
This, in about three minutes was removed and ex- 
amined by the microscope : it appeared to be trans- 
parent ; and although examined for some time, did 



50 ON THE PROPERTIES OF PUS. 

not change in any respect from the appearance it 
at first exhibited. 

This experiment proves, that the fluid, formed 
during exposure, is not Pus at the time of its for- 
mation. 



EXPERIMENT VII. 

The ulcer was wiped, and four very small pieces 
pf talc applied upon different parts of it ; immedi- 
ately afterwards the whole was covered with a plas- 
ter of common cerate, spread upon lint, to prevent 
the evaporation of the fluid. 

In 5 minutes — one of the pieces of talc was re- 
moved, and the fluid on its surface examined ; 
which appeared like a thin transparent jelly, divid- 
ed into masses ; but in which no globules could be 
distinguished. 

In 10 minutes— another piece was examined, and 
the appearance was like the former, but, at the bot- 
tom, a number of small globules could be readily 
discerned. 



ON THE PROPERTIES OF PUS. 51 

In 15 minutes — a third piece was examined, 
and the whole mass appeared to be made up of 
small globules ; but these were almost transparent, 
and seemed to become more distinct and opaque 
while looking at them. 

In 20 minutes — the fourth piece was examined, 
and the globules were found more numerous and 
opaque, like those of common Pus. 

From this experiment we find that Pus, at its for- 
mation, does not contain globules ; but is a transpa- 
rent fluid, of a consistence, in some sort, resembling 
jelly, and that the globules are formed while it lias 
upon the surface ; requiring, in some instances, 
fifteen minutes for that purpose. 

To see how far the formation of the globules de- 
pended upon the fluid remaining in contact with the 
granulations, the following comparative experiment 
was made. 



EXPERIMENT VIII. 

The ulcer being exposed and wiped dry, two 
pieces of talc were applied, to different parts of its 



52 ON THE PROPERTIES OF PUS. 

surface, and the whole covered as in Experiment 
VII. In five minutes, one piece was removed, and 
the transparent fluid, mentioned above was met 
with ; but no globules. The surface of the talc, on 
which the fluid lay was then covered with another 
piece of talc, to prevent the fluid coming in contact 
with the granulations, and it was applied again to 
the ulcer. In twentv-five minutes more, it was ex- 
amined by the microscope ; as also the fluid upon 
the other piece of talc, which had remained thirty 
minutes, and, in both of them, the globules were 
distinct and very numerous ; but most so upon the 
portion of talc in contact with the ulcer. 

This proves that, after the fluid is once separated 
from the vessels, the formation of globcfles i& a 
change taking place within itself, independent of the 
granulations which secrete it. 



EXPERIMENT IX. 

A piece of talc was applied as before, and the 
whole ulcer covered for two minutes ; the piece of 
talc was then removed and examined by the micro- 
scope : at first, no globules appeared. The exami- 
nation was continued five minutes ; in which time 



ON THE PROPERTIES OF PUS. 5$ 

the globules became exceedingly distinct to my 
own eye, and to the eye of another person well 
versed in microscopical experiments. 

This experiment was repeated several times ; but 
the quantity of fluid was in general so small, that it 
evaporated to dryness before the change into glo- 
bules took place. 

From this last experiment, it is not only evident 
that the formation of globules in matter is a change 
that takes place in the fluid after it is secreted ; but 
it further proves, that the globules are formed in a 
much shorter time when the (fluid is exposed, than 
when kept from the air. And, we are led, from 
the whole of these experiments, to conclude that the 
time required for the formation of Pus, in the state 
We commonly find it upon a healthy ulcer, varies ac* 
cording to circumstances, and is from five minutes 
to twenty. 



E 2 



CHAPTER II. 

GENERAL 0RSERVATI0NS ON ULCERS ON THE LEGS. 

X HE treatment of ulcers on the legs is by no 
means confined to the practice of military hospitals ; 
the disease is too frequently met with in all large 
cities, and wherever a number of labouring men are 
employed. But in no situation is their treatment, 
as a general practice, an object of so much impor- 
tance as in the army ; where the disease not only 
brings distress upon the individuals, but deprives 
the public service of a greater number of men than 
the country, in time of war, is able to afford. 

The frequency of this disease, with which all our 
public hospitals are crowded, gives the surgeons be- 
longing to these institutions ample opportunities of 
seeing such ulcers in all their different states ; of 
considering their nature, of comparing the effects of 
different modes of treatment, and of ascertaining, by 
experimental inquiry, what are the speediest as well 
as the best means of effecting a cure. 



GENERAL OBSERVATIONS, &C. 55 

To this inquiry I was led at a very early period, 
both by the precept and example of the late Mr. 
Hunter, whose active mind was always aiming at 
the improvement pf his profession ; and rhe public 
situations in which I have been placed during the 
last twenty-two years, both abroad and at home, 
have afforded me opportunities of making a great 
variety of observations. 

Ulcers on the legs have naturally attracted the 
attention of surgeons in all ages, and many very 
valuable works have been written on the treatment 
of them. On a careful examination of these pro* 
ductions, it will be found that this branch of surgery 
has been progressively improving, along with 
anatomy, and the knowledge of the animal (Econo- 
my ; and we must consider that it is, as well as 
them, still capable of further improvement. These 
ulcers are* to be regarded as a distinct consideration 
from those which occur in the other parts of the 
body ; since they vary among themselves in a much 
greater degree. This may be considered as arising 
from the following causes. 

The legs, by their situation, are more remote 
from the source of the circulation than the other 
parts of the body, and are therefore less perfectly 
supplied with pure blood. In many, and those the 



56 GENERAL OBSERVATIONS ON 

most usual positions of these limbs, the blood, 
in its return to the heart, is obliged to ascend against 
its own gravity, which retards its progress ; and 
thus the smaller vessels are kept in a state of to<* 
great distension and resistance from the pressure of 
this column of blood. 

From these circumstances it must appear, that 
the legs even in health are weaker in their vital 
powers than the rest of the body ; and when, from 
previous accident or disease, new parts are to be 
formed, the actions in the smaller arteries, by 
.which this should be effected, are impeded by the 
languid state of the circulation in the veins of the 
limb, whenever the body is put into an erect 
posture. If, on the other hand, to obviate this 
disadvantage, the body be kept for any length of 
time in a recumbent position, this is found so in- 
jurious to the general health, as in that way to 
interfere with the production of healthy granulations. 

This deficiency of vital powers in the legs, when 
compared with the rest of the body, occasions them 
to be more readily affected by every thing that 
weakens or disturbs the constitution ; and when in 
a diseased state, the symptoms will of course 
be influenced by the natural or acquired peculiari- 



ULCERS ON THE LEGS. 57 

ties, as well as by the actual state of the constitution, 
with respect to strength or weakness. 

As no two constitutions are exactly similar, so it 
happens, that an ulcer on the leg has not in any 
two persons exactly the same character ; for what- 
ever general resemblance one may have to another, 
there will be found also some peculiarities by which 
they may be distinguished. It is therefore not 
sufficient for the cure of such ulcers, that the 
surgeon should be acquainted with the general 
treatment ; a knowledge of these distinguishing 
» peculiarities, and their probable causes, is also 
necessary to enable him to treat with success the 
cases of those individuals who may be entrusted to 
his care. 

As it is the influence, which the state of the 
general system has upon ulcers on the legs, that 
gives to them a variety of dispositions, it does not 
unfrequently happen that such ulcers on the same 
person shall at different times, from the changes 
which have taken place in the constitution, require 
very different modes of treatment. 

From these observations it must appear obvious, 
that there is no probability that any one medicine 
can ever be discovered, which, whether internally 



58 GENERAL OBSERVATIONS ON 

administered, or locally applied, shall have powers 
adapted to the cure of all ulcers on the legs ; and 
it would appear, the idea that such a medicine 
may exist, has retarded very considerably, the 
advancement of our knowledge in the treatment of 
ulcers, by inducing surgeons to make use of the 
same applications to ulcers very different in their 
kinds. 

As no general medicine therefore can be ap- 
plicable to all ulcers, our study should be to 
ascertain the real powers of those medicines we 
already possess, and to discriminate the- different 
kinds of ulcers to which they are respectively 
adapted. 

While the doctrine of the humours was in general 
repute, internal medicines were supposed to be 
capable of removing almost every disease, and, 
among the rest, ulcers on the legs ; but practice did 
not confirm this theory ; and external applications 
were of necessity employed, before the cure could 
in many cases be effected. 

When, from the advancement of our ••-knowledge 
of the animal (Economy, it was asce, I "hat 

every part of the body has actions going' W within 
itself for its own increase, for repairing the waste 



ULCERS ON THE LEGS. j9 

naturally taking place, and restoring parts that have 
been destroyed ; and that these actions in the dif- 
ferent parts can be influenced by stimuli, locally ap- 
plied, both more immediately and more efficaciously 
than through the medium of the constitution, local 
applications to ulcers were naturally preferred to 
internal medicine ; and experience has sanctioned 
this preference. 

The number of external applications recommend- 
ed for the cure of ulcers on the legs, is very great ; 
many of these have, by their effects, established a 
reputation beyond all dispute, and are in very gene- 
ral use. Others are of a more doubtful character, 
their healing powers resting upon hypothetical rea- 
soning, derived from their effects upon dead animal 
matter, as being dryers, and by that means, causing 
parts to skin over ; effects which do take place un- 
der their use, but do so equally soon under the use 
of other medicines, which are known to have no 
such properties. 

It has been a question, whether all ulcers on the 
legs ought to be healed, even when we have the 
power of doing it. If this question is examined on- 
ly so * respects the origin of the ulcer, it is ve- 
ry readil , c,aswered ; for if the ulcer is a breach in 
the solids in consequence of an accident, there can 



60 GENERAL OBSERVATIONS ON 

be no doubt that the breach should be repaired, and 
the parts reinstated as soon as possible ; and if the 
ulcer arises from disease, there can be as litde doubt 
that the disease should be cured. But this question 
has been considered in another point of view ; it 
has been supposed that an ulcer once formed, has a 
power of drawing off, from the general system, im- 
purities which do not find a ready passage by the 
natural outlets of the body ; and therefore, although 
the body went on very well before such an ulcer was 
formed, when once this new channel is opened, and 
the impurities of the blood have taken that course, 
if it be suddenly stopped, they may not readily go 
off with the natural excretions ; and by being con- 
fined, may do a great deal of harm. 

This theory is very plausible, and while the doc- 
trine of the humours was generally believed, must 
have been unanswerable. But if the production of 
Pus be an action of the parts surrounding the ulcer 
for their own recovery ; if it be independent of the 
general system, otherwise than as it occasions a 
greater supply of blood than usual, to be sent to that 
part, then this theory must fall to the ground. 

From these observations it appears, that the dif- 
ferent kinds of ulcers on the legs, may be safely 
healed, there being no chance of any thing being 



ULCERS ON THE LEGS. 61 

thrown back, upon the general system, or retained 
there, in consequence of their cure. 

There are circumstances, however, in which it 
would be improper to heal an ulcer on the leg ; but 
these are totally independent of the theory I have 
endeavoured to refute. 

If a patient of a gouty habit has an ulcer on the 
leg, which is evidently affected by the gout, having 
regular attacks of pain returning at stated periods, 
and those attacks similar to what the same person 
had experienced from gout in other parts ; under 
such circumstances, any attempt to heal the ulcer is 
improper ; for if it should be attended with suc- 
cess, the gout may fall upon some more important 
part. 

There are many constitutional irritations, equally 
unintelligible with the gout, which occasionally fall 
upon the weakest or most irritable parts of the body. 
If it is found that an ulcer upon the leg breaks out 
whenever the constitution is disturbed, and if, when 
that happens, no other part is affected, it would be 
imprudent to heal that ulcer. Many people are af- 
fected in the spring by head-aches, ulcers on the 
throat, pains in the chest, eruptions on the skin, 
which ever is the weakest or most irritable part in 



62 GENERAL OBSERVATIONS ON 

the individual who is liable to such attacks ; if any- 
such person should have an ulcer on the leg, and the 
constitutional affection, whatever it may be, should 
fall upon the leg, now rendered more susceptible of 
such attack than any other part of the body, it 
would be imprudent to interfere, or attempt to heal 
that ulcer. 

That the periodical attacks just stated, with which 
every one must be perfectly acquainted, are consti- 
tutional affections falling upon particular parts, and 
not really a disease in the parts themselves, will be 
illustrated by the following instance ; and, were it 
necessary, a great many others might be given. 

A gentleman, who for many years was subject 
every spring to violent attacks upon his chest, had 
a disease which took place in the bladder, of a very 
distressing kind. As soon as that viscus became the 
weakest and most initable part of the body, he lost 
entirely the periodical returns of the complaint in 
the chest ; they fell upon the bladder ; so that, inde- 
pendent of the constant symptoms peculiar to the 
complaint, he had regular attacks, at intervals of 
some months, of the most violent irritation in that 
viscus. 



ULCERS ON THE LEGS. 63 

When any ulcer has existed on the leg for a great 
many years, it becomes an habitual disease, difficult- 
ly removed, and when it has been healed breaks out 
again ; the parts readily falling back into a state to 
which they had been long accustomed. There is, 
however, no reason why the ulcer, under these cir- 
cumstances, should not be removed, unless the pa- 
tient be very infirm or old. 

At a late period of life it is imprudent to make 
the smallest change in the (economy of the body, 
even in those respects which may appear to its ad- 
vantage ; for the smallest disturbance spmetimes 
proves fatal. 

If, in a weak state of body, a copious evacuation 
by stool has been immediately followed by death ; 
if the drawing off the water by the catheter, when it 
has been too long retained, has had a similar con- 
sequence in the course of a few hours ; both of 
which events I have witnessed ; it shews that the ac- 
tions of the vital organs cannot go on under such 
circumstances, if the smallest violence be committed 
upon any part of the machine, even where it is not 
attended with any loss to the general system ; for 
in both the cases which have been mentioned, the 
contents that were evacuated must have been some 



64 GENERAL OBSERVATIONS ON 

time separated from the system, and deposited in 
their proper reservoirs. 

The removal of any ^habitual irritation, in such a 
state of body, may be productive of harm. A per- 
son long accustomed to drink a dram in the morning, 
on leaving it off, has lost his health ; the irritation of 
an ulcer may have an effect upon the general sys- 
tem, of which it will be dangerous to deprive it. The 
healing of an ulcer on the leg, as it prevents so much 
blood from being carried to that part, for the forma- 
tion of Pus, may, when the machine is falling into 
decay, increase the quantity carried to the vessels of 
the brain, and produce apoplexy, by causing sojne 
of them to be ruptured. 

There is a curious effect of approaching death, 
which has been sometimes improperly attributed to 
the treatment of the surgeon. An ulcer of twenty 
years standing sometimes heals up of itself in the 
course of a few days, and the patient dies some 
hours after, or at least in a very short time. This 
circumstance, of the healing of the ulcer, appears 
to be an effect of that change which the general sys- 
tem frequently undergoes previous to its dissolution, 
and corresponds with the sensation of unusual health, 
often experienced immediately before a severe ill- 
ness, and also immediately before death* 



ULCERS ON THE LEGS. 65 

GENERAL DISTRIBUTION OF ULCERS INTO THEIR 
SPECIES. 

To render the medicines we employ as generally 
useful as possible, it appears a very desirable object 
to distinguish the various ulcers on the legs, occur- 
ring in practice, into different kinds, as far as we are 
enabled so to do upon general principles ; and then 
to state the particular remedies which more properly 
belong to each of these classes. 

If a plan of this kind can be carried into effect, 
which is the object of the following observations, a 
surgeon, as soon as the nature of an ulcer shall be 
ascertained, will very much have circumscribed his 
subsequent labours ; since he will only have to dis- 
cover, by trials, which of the medicines found most 
applicable to that species of ulcer will best agree 
with the particular case under consideration. 

A knowledge of all the medicines fitted for each 
species of ulcer will also be attended with another 
advantage ; for it will be found, as will be hereafter 
more fully explained, that the same application, 
however it may agree at first, will, if used beyond 
a certain time, lose its good effects, and therefore 
I 2 



66 GENERAL OBSERVATIONS ON 

will require to be changed for some other of similar 
powers. 

From all the consideration that I have been able 
to bestow upon the subject, and my opportunities 
have been very extensive, I am led to believe, that 
ulcers on the legs differ from one another according 
to the following circumstances : local peculiarities, 
constitutional peculiarities, peculiar dispositions of 
the parts or of the constitution, and diseased dispo- 
sitions of the parts or of the constitution. I have 
therefore divided them into six different species, 
each of which requires a very distinct and different 
mode of treatment. 

1. Ulcers in parts that have sufficient strength to 
carry on the actions necessary for their recovery. 

2. Ulcers in parts that are too weak for that pur- 
pose. 

3. Ulcers in parts whose actions are too violent 
to form healthy granulations, whether this arises 
from the state of the parts or of the constitution. 

4. Ulcers in parts whose actions are too indolent, 
whether this arises from the state of the parts or of 
the constitution. 



ULCERS ON THE LEGS. 67 

5. Ulcers in parts which have acquired some spe- 
cific action, either from a diseased state of the parts 
or of the constitution* 

6. Ulcers in parts which are prevented from heal- 
ing by a varicose state of the superficial veins of 
the upper part of the limb. 

These six species of ulcers are to be considered 
separately ; and in stating the different applications 
suited to each species, they will be noticed, where 
they admit of it, under four different forms ; for the 
same form of medicine does not always answer in 
different cases of the same species of ulcer, to which 
the virtues of that medicine may be generally appli- 
cable. In one case, the medicine shall agree best in 
the state of vapour ; in another, in a fluid state ; in 
others, in the form of ointment ; and in others again, 
in the form of powder. 



CHAPTER III. 



OF ULCERS IN PARTS WHICH HAVE SUFFICIENT 
STRENGTH TO CARRY ON THE ACTIONS NE- 
CESSARY FOR THEIR OWN RECOVERY. 



W HEN an accident happens to the leg of a per- 
son in perfect health, by which a portion of the skin 
and muscles is deadened, or only simply divided, if 
they are not united by the first intention, an ulcer is 
the consequence. Such an ulcer requires no medi- 
cated applications for its cure, the parts having suf- 
ficient powers within themselves to restore the lost 
muscles, cellular membrane, and skin, by the pro- 
cesses of inflammation, suppuration, granulation, and 
cicatrization ; these being the means instituted by 
nature for the restoration of parts. 

In this species of ulcers the matter or pus, which, 
is formed in the stage of suppuration, is white, 
thick, readily separates from the surface of the 
ulcer, and when diluted, and examined in a 
microscope, is found to be made up of small 



ULCERS ON THE LEGS, &C. 69 

globules swimming in a transparent fluid. The 
granulations are small, florid, and pointed at the 
top ; as soon as they have risen to the level of the 
surrounding skin, those next the old skin become 
smooth, and are covered with a thin, semi-transpa- 
rent film, which afterwards becomes opake, and 
forms cuticle. 

All that is required in the treatment of such an 
ulcer is, to keep the surface clean, and prevent the 
natural processes from being interrupted in the 
course of the cure ; this is, in general, best done 
by the application of dry lint, to absorb and retain 
the matter, which serves as a soft covering for the 
granulations, that appears necessary to preserve 
them in a healthy state, and a pledget of any simple 
ointment over the whole, to prevent evaporation of 
the matter, that the dressings may be readily, and, 
at proper intervals, removed. 

This mode of treatment, were it not for the 
peculiarities of the constitutions of different patients, 
would apply equally to all ulcers of this species ; 
but these pesuliarities are so various as to require 
particular consideration. 

Although healthy ulcers require no medicated 
application to be made to them in any case, it is 



70 ©F ULCERS IN PARTS. 

necessary that the dressing should be of a kind 
that does not disagree with the granulations, or 
surrounding skin, since if it does so, in the slightest 
degree, the progress of the cure will be retarded. 

By some patients a roller applied moderately 
tight, to secure the dressings, will be found so 
uneasy to the parts, as to make the ulcer lose its 
healthy appearance, which will be resumed on 
leaving off the bandage. Several cases of this kind 
have fallen under my care. 

In some instances the application of ointment will 
disagree even with the neighbouring skin. In 
others, when superficial, the ulcer will not skin over 
while the surface is kept moist, and confined from 
the air ; but if exposed, and allowed to scab, it will 
heal. 

That the modes of treatment which most com- 
monly answer, and consequently ought to be in ge- 
neral use, prove hurtful in particular cases, must be 
referred to the constitution, which has its influence 
over every component part of the body. They are 
entirely unconnected with disease ; for as soon as 
the offending application is removed, the ulcer con- 
tinues its progress towards a cure. These peculiari- 
ties are deserving of particular notice, since they are 



WHOSE ACTIONS ARE HEALTHY. 71 

equally liable to occur in the other species of ulcers 
which we are about to consider, as in these of the 
healthy kind ; and if not sufficiently attended to, 
may be mistaken for the effects of diseases, and may 
lead to very improper modes of treatment. 

As in the management of ulcers of this species the 
great object is a knowledge of the peculiarities of the 
constitution, if there are any, an inquiry should be 
instituted into the effects of different applications to 
the same person upon former occasions ; whether 
oily or watery substances agreed best with the skin; 
whether exposure to the air disposed former ulcers to 
form scabs, or the reverse ; and if scabs were formed, 
whether the parts underneath skinned over or not. 
From such questions a surgeon will in general pro- 
cure material information, and frequently be led at 
once to the most judicious mode of practice ; while, 
on the contrary, a want of attention to these cir- 
cumstances may be the cause of protracting the cure 
for a considerable time. The truth of this obser- 
vation cannot be better illustrated, than by mention- 
ing the following circumstance. A boy at school, 
by some accident, had several small ulcers on his 
leg, on which account he was immediately sent 
home. As he was the son of a nobleman of high 
rank, every attention was paid to them, all kinds of 
dressings were tried, but without the desired effect. 
Under these circumstances, it was proposed (as 



72 OF ULCERS IN PARTS 

there was nothing in the appearance of the ulcers to 
account for their backwardness in healing) to leave 
off all dressings, and make him wear a pair of loose 
trowsers, night and day, to prevent any thing from 
adhering to their surface : under this mode of treat- 
ment they readily healed. 



APPLICATIONS CONSIDERED, WITH REFERENCE TO 
THIS SPECIES OF ULCER. 

1 . In the form of vapour. 

Nothing should be applied in this form, although 
it is sometimes done by way of fomentation. The 
effect, however, is pernicious, since the granulations 
are thereby rendered looser in their texture, and 
less disposed to form skin. 

2. In a fluid form, or moist state. 

Poultices are not less improper than fomentations. 
Alcohol diluted in different proportions is found, in 
many instances, to dispose the granulations, when 
upon a level with the neighbouring skin, to form a 
scab. When that object is desirable, this method 
will answer the purpose. 



WHOSE ACTIONS ARE HEALTHY. 73 

3. In the form of ointment. 

Ointments are seldom employed in this species of 
ulcer with any other view than to prevent evapora- 
tion, and are not usually in contact with the granu- 
lations ; for this purpose the simplest forms appear 
to be the best, as that made of equal parts of white 
wax and olive oil ; the ceratum epuloticum is sup- 
posed, from the lapis calaminaris which it contains, 
to assist or hasten the formation of new skin. No- 
thing has occurred within my own experiment, 
which at all tends to favour this opinion. 

The great objection to the common simple oint- 
ments — as cerate, and others of that kind, is, that 
they sometimes disagree with the skin, even when 
recently made, and in the most perfect state ; but 
when allowed to become rancid, which they do by 
being long kept, they too often irritate to a very 
considerable degree, and aggravate the symptoms 
they were meant to relieve. 

As the army surgeons are supplied with oint- 
ments only once a year, or once in two years, and 
these ointments, from being made in veiy large 
quantities, are more liable to suffer in the making, 
by the heat employed rendering the oil empeure- 
matic ; it would be a much better plan to give an 



74f OF ULCERS IN PARTS 

allowance of white wax and olive oil to each regi- 
mental surgeon, who could make them into oint- 
ment in small quantities, as he had occasion, so as 
always to have it in a recent state. 

In the West Indies, during the last war, oint- 
ments were supplied very liberally by government ; 
but in that country the heat rendered them so ran- 
cid, that they became very stimulating applications, 
and only adapted to ulcers of an indolent nature. 

4. In form of powder, or in a dry state. 

If it be thought advisable to form a scab upon 
the surface of the ulcer, this may be soon effected, 
by applying a small quantity of any inert substance 
in form of powder ; but, as dry lint will answer the 
purpose, I should for many reasons prefer it. 

When either of these means are employed, n<> 
thing should be allowed to come in contact with the 
powder or lint applied to the ulcer. This is best 
prevented by putting a small bolster of linen on 
each side of the ulcer, and over these a bandage, so 
that the bandage may form a kind of bridge over 
it, and be kept at some distance, while it defends 
the surface from any accidental violence. 



WHOSE ACTIONS ARE HEALTHY. 7.» 

Dry lint is the common dressing in use, and, as a 
general practice, is the best. When the ulcer does 
not form a sufficient quantity of Pus completely to 
to moisten the lint in twenty-four hours, the dress- 
ings should only be changed every other day, as 
the removal of the lint when it adheres, even slight- 
ly, disturbs the formation of new skin, and makes 
the granulations afterwards less disposed to form 
it. 

A bandage applied tolerably tight, where there is 
no peculiarity in the constitution to forbid its use, 
gives a firm support to the muscles and skin, which 
are frequently loose and flabby from the want of the 
natural healthy movements of the limb. It is also 
a defence to the newly formed parts. 



CHAPTER IV. 

OF ULCERS IN PARTS THAT ARE TOO WEAK TO 
CARRY ON THE ACTIONS NECESSARY FOR THEIR 
RECOVERY. 

U LCERS of this kind differ from those in healthy 
parts ; the granulations are larger in size, rounded 
upon their external surface, less compact in their 
texture, and semi-transparent. When they arrive 
at the surface of the body, they do not readily form 
skin, and frequently continue to rise still higher, 
and then entirely lose the disposition to form new 
skin. In a still more weakened state of parts, the 
granulations, after having gone on favourably for 
several days, shall all at once give way, and be ab- 
sorbed into the constitution, leaving the ulcer as 
broad and deep as it was before, the granulations 
not being strong enough to preserve themselves 
from decay. 

Ulcers may from the beginning exhibit these ap- 
pearances of want of strength in the newly formed 



OF ULCERS IN PARTS, &C 77 

parts ; or they may at first go on for a few days in 
every respect like those in healthy parts, but be- 
come unable to do so beyond that period, and the 
granulations then show signs of weakness. For 
granulations of the most healthy kind, if they are 
not skinned over in a certain time, appear to lose 
their original strength, and fall into a weak state. 

Ulcers on the legs have been already stated to be 
influenced, in a very considerable degree, by the 
natural peculiarities of the constitution ; they are 
found to be still more so by any thing that affects, 
in the slightest manner, the patient's general health. 
The appearance of the granulations undergoes a 
change, upon the least diminution of constitutional 
strength ; and if that be restored, the granulations 
return to their former state ; so that an ulcer of a 
healthy, kind becomes in general a very accurate 
index of the strength or weakness of the constitu- 
tion. 

The influence produced upon ulcers by any dimi- 
nution of the constitutional strength is the greater, 
the further the seat of the ulcer is removed from 
the source of the circulation. If a person in a weak 
state has two ulcers on the same leg, one near the 
knee, the other near the ankle, as he recovers his 

strength the two ulcers will assume a more favoura- 
G 2 



78 Or ULCERS IN PARTS WHOSE 

ble appearance ; but the effect will not be equal in 
both ; that nearest the knee will show the first 
signs of amendment, and will go on healing faster 
than the other. This may by many be considered 
as accidental, but the instances of it which occur, 
appear to be sufficiently numerous to prove that it 
arises from some general principle. 

Whatever disturbs the constitution seems to pro- 
duce a temporary imperfection in the actions of the 
animal osconomy ; for while the body is in that state, 
the progress of healing in an ulcer appears to be at 
a stand. We see this effect produced occasionally 
by anxiety of mind. A small ulcer, which the pa- 
tient is led to suspect may be venereal, will some- 
times remain, without making the smallest progress 
towards a cure, during fourteen days, in conse- 
quence of a state of anxiety brought on by this sus- 
picion : but the moment the mind is at ease, the 
ulcer will begin to heal, and get well in a few days. 

These effects upon ulcers, produced by the state 
af the constitution, are greater in weak and delicate 
people, than in the strong and robust. They seem 
to take place in the greatest degree in those consti- 
tutions, which, from the effects of particular modes 
of life, and the influence of different climates, are 
very susceptible of impressions. The following ob- 



POWERS ARE TOO WEAK. 79 

servation offers a confirmation of this opinion. In 
the year 1778, after the naval action between the 
English and French, the wounded seamen, belong- 
ing to admiral Keppel's fleet, were all carried into 
the Naval Hospital at Plymouth : among them were 
several hundred patients with ulcers, from acci- 
dents on board of ship, and most of them on the 
legs. Whenever there was any violent and sudden 
change in the weather, from a dry to a moist state, 
which is very often the case in October and No- 
vember, on that part of the coast, it had an imme- 
diate effect upon all the ulcers in the hospital ; giv- 
ing them universally an unhealthy appearance. 
Instead of Pus, the granulations threw out an exu- 
dation of coagulating lymph, which lay upon the 
surface of the ulcers, looking exactly like melted 
tallow ; and when the weather changed again, and 
became dry, they put on a more healthy appear- 
ance. 

For the cure of this species of ulcer it is neces- 
sary to pay attention to the constitution ; such me- 
dicines as strengthen are to be employed, as bark, 
and steel ; and whatever is found to affect the con- 
stitution unfavourably is to be avoided as much as 
possible. By these means the local treatment will 
be materially assisted. In this languid state it is 
common to give wine and cordial medicines ; but 



80 OF ULCERS IN PARTS WHOSE 

the treatment of any set of men should be adapted 
to their modes of life ; and with soldiers, and in- 
deed the whole class of working people, porter is of 
much more service than wine ; it does not heat so 
much, and they in general like it much better. In 
the present war, the hospitals under Sir John Mac- 
namara Hayes were liberally supplied with porter, 
and the men recovered their health very fast under 
its use. 

The first object, with respect to the ulcers 
themselves, is to prevent the granulations from 
rising higher than the edge of the surrounding skin, 
since it is a fact well established, that when they 
are higher than the level, they are not disposed to 
form skin. This is not sufficiently attended to 
in common practice ; but another mode is adopted, 
which is erroneously supposed to produce the same 
effect. Escharotic medicines are used to eat down 
the granulations, whenever they are found to be too 
high, and in this way they are reduced nearly to 
the proper level. There can be no doubt, that if, 
by any means, the granulations could be prevented 
from rising beyond the surface, it would save a 
great deal of pain to the patient, and be attended 
with other advantages ; and this may be done, as 
will be explained, by making use of dressings 
adapted for that purpose. 



POWERS ARE TOO WEAK, 81 

It becomes a question, how far escharotics should 
be employed, even when the granulations, by- 
inattention, have been allowed to become luxuriant ; 
since the very act of destroying the upper part of 
the granulations seems to increase the growth of 
the part that remains, so that the disposition for 
luxuriance in the new flesh is not corrected, but 
rather increased, and there is a constant necessity 
for making use of the same harsh means of keeping 
them within bounds, till they shall be disposed to 
form skin ; a process which would have taken place 
much sooner under another mode of treatment. 
If, on the other hand, such medicines are used as 
have a stimulating power, which is proportioned 
to the strength of the granulations, the super- 
ficial luxuriant parts, to which they are immedi- 
ately applied, will be absorbed, and those un- 
derneath will be checked in their growth. Instead, 
therefore, of touching the surface of such ulcers 
with the lunar caustic, blue vitriol, red precipitate, 
or any other of the escharotics in use, the same 
medicines compounded with other substances t 
which will diminish their activity, and render them 
only strong stimulants, may be used with advantage. 

To illustrate the difference between the effects 
of escharotics and of stimulants, in keeping down 
granulations, I shall mention what happens in the 



82 OF ULCERS IN PARTS WHOSE 

case of warts ; which are only a luxuriancy of 
growth from the cutis, and, like granulations, and 
all other newly-formed parts, are weaker in their 
living principle than original parts. 

If warts are touched by escharotics, it is found 
that their growth is rather increased than stopped 
byjsuch treatment; and they cannot be removed 
by these means, unless the caustic acts beyond the 
basis of the wart, and destroys a part of the skin 
underneath. But if a stimulating application, such 
as the powder of savin mixed with aerugo aeris, is 
employed, it excites a degree of action in the wart 
itself, whose vital powers are weak, and, in con- 
sequence of the degree of action thus produced 
being greater than the parts are able to sustain, the 
absorbents take them back into the circulation, and 
the wart is wholly removed ; but if the same ap- 
plication is made to the common skin, it produces 
no effect at all. 

As the great object in the healing of an ulcer is 
to have the new flesh, by which it is filled up, as 
strong in its living powers as possible, that it may 
not afterwards break out again, every thing that 
can conduce to that end is deserving of attention. 
It is reasonable to conclude, that in the growth of 
animal substance, as of vegetables, where there is a 



POWERS ARE TOO WEAK. 83 

rapid increase, the parts growing are weaker than 
where it is slow ; and if the granulations, which are 
already growing beyond their strength, have this 
rapidity increased by partial removals, they must in 
reality be rendered weaker than they were before. 
If this reasoning be just, which there is reason to 
believe it is (since the observations on which it is 
founded are taken from practice) the treatment of 
granulations ought to be regarded in a point of view 
that has hitherto been little considered. Their 
growth ought to be kept back in an early stage of 
their formation, by such resistance as they are just 
able to overcome ; which will at the same time re- 
tard their increase, and allow them to acquire 
strength by their own actions ; for new-formed parts 
in a living body are strengthened in proportion to 
the action they are obliged to exert. This, however, 
is confined within certain limits, for if the actions 
are increased beyond the real strength of the parts, 
the absorbents remove them altogether, and an at- 
tempt is made to produce a new growth of granula- 
tions, strong enough to support the actions required 
of them. This they are sometimes unable to ac- 
complish, and the ulcer remains nearly stationary, 
till the stimulating application is removed. 

It is upon this principle that the pressure made by 
tight bandaging is found so useful in this kind of til- 



84 OF ULCERS IN P^RTS, WHOSE 

cer ; and it is from the same cause that those ulcers, 
which heal while the patient is walking and using 
exercise, are less liable to break out again, than those 
which are healed under the circumstances of rest 
and perfect quietness. 

I have dwelt the longer upon the necessity of at- 
tending to the strengthening of granulations, at their 
first formation, from finding, that after they are once 
formed they do not appear capable of becoming 
stronger, in the same degree ; but give way under 
the slightest increase of motion in the parts, even af- 
ter they have been allowed what might be consider- 
ed a sufficient time to acquire strength, and the ul- 
cer itself has been completely healed. We have 
daily proofs of this weakness of granulations, in all 
the stages of their growth, in our public hospitals. 
When a patient is first received with an ulcer in a 
very disturbed state, from improper treatment, with- 
out any distinct appearance of granulations, under 
the application of a poultice the surface will fre- 
quently become clean, and granulations will rise up 
in every part : these will increase, and appear to be 
strong and healthy (when superficially examined) 
while the patient remains in bed ; but as soon as he 
gets a little better, and walks about, the ulcer 
spreads ; the motion of the limb being greater than 
the granulations can support, on which account they 



POWERS ARE TOO WEAK, 85 

are absorbed, and taken back into the constitution. 
If the patient be kept in bed, the ulcer will heal, and 
he may leave the hospital perfectly well ; but as 
soon as he returns to his usual exercise the granu- 
lations, too weak to support themselves, give way, 
and the ulcer breaks out again, and becomes nearly 
of the same size as at first. 

As this is one of the most common species of ul- 
cer to which soldiers are liable, it is of the utmost 
importance that military surgeons should be made 
acquainted with the cause why many of them are so 
liable to break out again ; that they may avoid this 
consequence, and by their mode of treatment enable 
their patients to return to their duty as soon as pos- 
sible after the ulcer shall be healed. 

Ulcers on the leg may be, in the first instance, of 
the truly healthy kind, but from their size the parts 
towards the centre may be so long kept from skin- 
ning, that the granulations may become weak, and 
when they have arisen to the surface may remain 
stationary, without shewing any disposition to form 
skim When this is the case they generally, after a 
day or two, acquire a fresh growth, and become 
luxuriant. 

In the treatment of such ulcers it is therefore 



86 OF ULCERS IN PARTS WHOSE 

proper to attend to this circumstance, and whenever 
it is seen that the granulations, though come to the 
proper height, do not form a thin semi-transparent 
pellicle upon the surface they are to be considered 
as weak parts, and treated accordingly. The sim- 
plest and best mode, where the constitution has no 
peculiarity which forbids it, is pressure ; this may 
be made by a piece of thin lead over the dressings, 
and will be assisted by a tight bandage on the limb, 
which by compressing the parts, makes the circula- 
tion through the veins less tardy, than when the 
parts are left to themselves. 



APPLICATIONS CONSIDERED WITH REFERENCE TO 
THIS SPECIES OF ULCER. 

It is questionable whether we have any power of 
strengthening parts by local applications ; but it is 
equally questionable whether the constitution can 
really be made stronger by the use of internal me- 
dicine ; since absolute strength can only be convey- 
ed to the body by means of nutriment, which is 
not contained in the substances used in medicine. 

It is, however, by no means improper, in the prac- 
tice of physic, to call those medicines strengtheners 
which, by their action on the internal membrane of 



POWERS ARE TOO WEAK. 87 

the stomach, increase the secretion of the gastric 
juice, so as to convert a greater proportion of the 
aliment into chyle ; or by their action on the ab- 
sorbents, stimulate them to take up a greater quan- 
tity of the chyle, and convey it into the circulation : 
or which, by regulating the actions of the different 
parts of the system, diminish the general expen- 
diture of the nourishment of the body : since all 
medicines which act in these different ways, do in- 
directly contribute to render the body stronger than 
it was before. 

The same observations apply, with equal propri- 
ety, to the applications made to ulcers in weakened 
parts. Whatever prevents the granulations from 
exhausting themselves by luxuriant growth,, or sti- 
mulates them to draw more abundant supplies from 
the arteries, does, in effect, render them stronger. 

1. In the form of vapour. 

The fomentations in common use to many other 
species of ulcer, are improper in those whose ac- 
tions are too violent for their powers to sustain, 
since the application of heat increases the actions of 
parts, gives them a greater tendency to become lux- 
uriant, and renders them still weaker than they were 
before. Fomentations sometimes give pain when 



88 OF ULCERS IN PARTS WHOSE 

applied to parts in a very weak state ; this happens 
when the action excited by their warmth exceeds 
what the parrs can readily perform ; and whenever 
this symptom occurs, they should be left off. 

Spirits of wine and decoction of poppies, in equal 
proportions, may be substituted with advantage for 
the common fomentations, but must not be applied 
hot. They often soothe the sensations of the parts, 
and lessen their actions* Where the granulations 
appear to be disposed to run into mortification, 
this application is sometimes the means of prevent- 
ing it. 

2. In a watery form or moist state. 

Poultices are not adapted to this species of ulcer, 
for the reasons already stated. 

The argentum nitratum in weak solution in wa- 
ter, the strength proportioned to the state of the 
ulcer, is one of the best applications in a watery 
form. 

3. In the form of powder. 

There are several medicines used in the form of 
powder to this species of ulcer ; of these the most 
common are bark, and the lapis calaminaris : the 



POWERS ARE TOO WEAK. 89 

bark is supposed to have a power of strengthening 
the granulations, and the lapis calaminaris of dis- 
posing them to form skin. I have very frequently 
had recourse to both of them, but cannot, from any 
experience of my own, speak in their favour ; never 
having seen the effects that are attributed to them 
sufficiently obvious to merit the character they have 
acquired. Powdered chalk and plaster of Paris 
have been brought into notice, as disposing granula- 
tions to form skin ; but such a power appears to be 
improperly attributed to them. 

Powdered carbon has been used with success, but 
its effects are more conspicuous in ulcers attended 
with irritability ; than those attended with weak- 
ness. 

Powdered rhubarb is an application which I have 
used to different species of ulcers, and ventured 
some years ago to recommend it to the notice of 
the public* It appears more particularly applica- 
ble to this species, having a power over the luxuri- 
ant growth of granulations, rendering them small 
and compact, and disposing them to form skin ; but 
if they have been permitted to rise considerablv 

* See Transactions of a Society for the Improvement of >Ie^ 
tlical and Chirurgical Knowledge, vol. i. 
H 2 



90 OF ULCERS IN PARTS WHOSE 

above the proper level, it is not powerful enough 
to lower them. 

The rhubarb is apt to form a crust upon the edges 
of the ulcer, which should be occasionally removed, 
to prevent the matter from being confined under it. 
This should be done with care, to avoid hurting the 
new skin which begins from the edges, and to the 
formation of which this crust seems to be favoura- 
ble. 

If the rhubarb alone is too stimulating, which is 
sometimes the case, adding one-fourth part of the 
powder of crude opium, makes it a milder applica- 
tion. 

It is to be understood, that when any of the pow- 
ders above-mentioned are used, a small piece of 
lint, nearly the size of the ulcer, is to be laid over 
the powder, and the whole covered by a pledget of 
simple ointment. 

4. In the form of ointment. 

Unctuous applications appear to disagree more 
frequently with ulcers of this kind than any others ; 
and in many instances where they have been long 
used, the omission of them will be followed, almost 



POWERS ARE TOO WEAK. 91 

immediately, by a more favourable appearance. 
This I have seen so often, as to have no doubt of 
the fact, and even where the powdered lapis calami- 
naris has been supposed to be beneficial, I have been 
inclined to suspect that it is in no other way than by 
defending the surface of the granulations from the 
ointment, which, before the powder was used, had 
been more or less in contact with them. 

Although ointments are often improper, it can- 
not be asserted that they are always so, it will 
therefore be right to try them in those cases where 
a cure is not obtained by means of the other appli- 
cations. 

The ointment which seems most applicable to 
cases of this kind, is the unguentum hydrargyri ni- 
trati, mixed with hog's lard, in the proportion of 
one to five. 

Common cerate, with a small proportion of the 
hydrargyrum nitratum rubrum, is also a useful ap- 
plication. Both these preparations give a check to 
the luxuriant granulations, and are best adapted for 
reducing them when they have risen to too great a 
height. 



92 OF ULCERS IN PARTS WHOSE 

After having enumerated the various medicines 
which may be used with success in different cases 
of this species of ulcer, it may be necessary to men- 
tion the order in which they stand in practice ; be- 
ginning with those most generally useful. 

The rhubarb seems to agree with the greatest 
number of patients, and is therefore the application 
to which the first trial should be given. Its effects 
are not to be decided upon for two or three days, as 
almost every application appears to be of service 
for that length of time ; but if the ulcer goes on fa- 
vourably for a week the medicine is certainly to be 
continued ; if on the other hand, after the third 
day the ulcer appears to be stationary, it is then to 
be left off. 

The argentum nitratum dissolved in water, and 
diluted till the solution, when applied to the tip of 
the tongue, feels slightly pungent, is to be adopted 
when the rhubarb does not answer ; and if this also 
disagrees, or does not produce any amendment in 
the ulcer, then the unguentum hydrargyri nitrati is 
to be used ; and if still no progress is made towards 
a cure, recourse may be had to the ceratum epulo- 
ticum, or any other common ointment, with the hy- 
drargyrum nitratum rubrum, in the proportion of 
half a dram to an ounce. 



POWERS ARE TOO WEAK. 93 

Which ever of these applications is used the ulcer 
should only be dressed once in the twenty-four 
hours, unless the quantity of discharge should prove 
so great as to require it to be done more frequent- 

When the ulcer is on the lower part of the leg, 
in whatever way it is dressed, care should be taken 
to support the muscles of the calf of the leg, which 
in general will be found very flaccid, and when the 
leg is lifted up from the bed, hanging loose from 
the tibia. Without such support, the ulcer will 
frequently resist every means that is used to make 
it heal. In this state of the limb, the arteries and 
veins are deprived of their lateral support, so that 
the circulation through the smaller vessels, is under 
circumstances unfavourable for the process of form- 
ing new flesh. 

To illustrate this, it may be proper to state the 
following case. A gentleman between sixty and 
seventy years of age, who had lived freely, had an 
ulcer take place a little above the inner ankle of the 
right leg ; this was at first neglected, as it did not 
give much pain, but in the course of eight or ten 
days, it began to spread so rapidly as to give alarm 
to the patient, and also to the surgeon who attended 
him ; under these circumstances I was called in, the 



94 OF ULCERS IN PARTS &C. 

patient was taking bark and opium internally very 
freely, and the ulcer was poulticed with bread and 
milk. From the appearance, I was led to consider 
this ulcer of the irritable kind, and directed some 
tincture of opium to be sprinkled on the surface of 
the poultice, but in two days there was no apparent 
amendment. I was therefore led to object to the 
poultice, and thought its weight might occasion the 
ulcer to spread ; the dressings were lint wetted with 
a solution of extract of opium in water, covered by 
an ointment of wax and oil : this in two days had in 
no respect arrested the progress of the ulcer which 
was spreading rapidly. Seeing the extremely flaccid 
state of the muscles, I was led to consider that alone 
as the cause of the ulcer spreading, and desired the 
limb to be well supported with a roller as high as 
the knee, and the same dressing continued. Under 
this treatment, in two days the ulceration had stop- 
ped, the granulations had put on a healthy appear- 
ance, and in a week's time, an ulcer three inches 
broad and five long, was nearly skinned over, and 
in a few days more was entirely healed. 



CHAPTER V. 



OF ULCERS IN PARTS WHOSE ACTIONS ARE TOO 
VIOLENT TO FORM HEALTHY GRANULATIONS; 
WHETHER THIS ARISES FROM THE STATE OF THE 
PARTS OR OF THE CONSTITUTION, 



W hen an ulcer takes place on the leg of a person 
of an healthy constitution, it can only be prevented 
frSm healing, under proper treatment, by the weak- 
ness of the parts ; but when the general system is 
not perfectly in that state, whether from some natural 
peculiarity, or some accidental disturbance, this will 
operate as a cause to prevent such an ulcer from 
getting well j and to make its apparance vary from 
that of an healthy ulcer. These changes, when 
they occur, are generally to be considered as under 
the influence of the constitution. There are three 
states of constitution by which the appearance of 
ulcers is most commonly influenced. The first is 
a generally disturbed state in which all the actions 
of the animal (economy are more rapid than in 



96 OF ULCERS IN PARTS WHOSE 

health, commonly known by the expression of the 
body being in an irritable state. 

The second is where the actions of the animal 
(economy are unusually languid which, to distinguish 
it from the former, is called an indolent state of the 
body. The third is where the actions of the animal 
ceconomy are interfered with by some disease af- 
fecting the system : when either of these states of 
the general habit take place, the ulcer acquires a 
correspondent disposition, and is called, irritable, 
indolent, or diseased. 

It would be natural to suppose these three dis- 
positions so widely different from one another, that 
an ulcer attended with irritability, one attended 
with indolence, and one attended by some specific 
diseased action, must be very readily distinguished 
by their external appearance. This, however, is 
by no means true ; for although in strongly marked 
cases there is no difficulty in judging of the nature 
of the ulcer from the state of the granulations, this 
mode of discriminating is not, in the greater number 
of instances, at all to be relied on. 

The disposition of an ulcer, like the disposition 
of a constitution, is only to be exactly ascertained 
by determining the actions which arise from the 



ACTIONS ARE TOO VIOLENT 97 

different impressions made upon it. From a want 
of attention to this mode of considering the subject, 
ulcers have been commonly supposed to be of the 
same kind, where the external appearances were 
nearly alike ; which has retarded the progress of 
our knowledge on the treatment of ulcers, by pre- 
venting a more judicious application of the medi- 
cines in use ; while, by employing them improperly, 
their character has been materially injured. 

In considering ulcers in parts, whose actions are 
too violent, attended by irritablity, it is proposed 
not only to treat of those which evidently are so in 
their appearance ; but to include all ulcers, what- 
ever their appearance may be, which locally or 
constitutionally partake so much of irritability, as to 
require sedative applications for their cure. This 
will be found to comprehend a much greater 
number of ulcers than could at first view be ima- 
gined. 

There are appearances which at once show the 
ulcer to be of an irritable kind, and these, when they 
are present, render all further investigation un- 
necessary. The following are the principal marks 
of irritability : 



93 OF ULCERS IN PARTS WHOSE 

The margin of the surrounding skin being jagged, 
and terminating in an edge which is sharp and un- 
dermined. The bottom of the ulcer made up of 
concavities, of different sizes. No distinct ap- 
pearance of granulations, but a whitish spongy 
substance, covered with a thin, ichorous discharge. 
Every thing that touches the surface gives pain, 
and very commonly makes it bleed. 

In proportion to the degree of irritability or dis- 
turbance, which has been produced in the action of 
the parts, so is the discharge altered from common 
pus to a serous fluid, and in some instances it is al- 
most simple water, as in the following case. 

A gentleman, 60 years of age, of a very irritable 
constitution, in March 1798 had a slight kick upon 
the inner ankle of the right leg, which at the time 
was not attended to ; it did not heal, and on the 
fourth day from the accident he became generally 
indisposed, which was considered to arise from the 
disordered state of his stomach ; he fainted away, 
and upon recovering himself had all the symptoms of 
a disturbed state of the constitution, in common lan- 
guage called fever : the sore upon the ankle inflam- 
ed, was exceedingly painful, the whole leg swelled, 
and the scarf skin separated from the cutis for an 
inch all round the ulcer, so that mortification was to 



ACTIONS ARE TOO VIOLENT. 99 

be expected. In this state I saw it on the seventh 
day, and directed a poultice of bread and water ; the 
serous discharge was very great, the pain in the part 
severe, and the constitutional indisposition unabat- 
ed. At the end of five weeks, by the different 
means used, which were principally the bark, his 
general health was in some measure restored, but 
the poultice had brought out pimples on the sur- 
rounding skin, and was therefore left off, and a sim- 
ple white ointment applied 5 the leg at this time 
continued swelled, and pitted when pressed. 

The ulcer was about half an inch square, and, in- 
stead of discharging common pus, it was a limpid 
water, which in the course of 24 hours completely 
wetted the compress and bandage ; this discharge of 
water evidently diminished the size of the leg, and 
in 1 1 days it was reduced nearly to the natural size j 
after which the ulcer began to heal, and in a fort- 
night longer skinned over. 

The ulcer, during the whole of this time, was in 
an uncommonly irritable state, could not bear the 
slightest pressure, and was attended with a great 
deal of pain till the last fortnight before it skinned 
over. 



100 OF ULCERS IN PARTS WHOSE 

A truly irritable ulcer is perhaps as distressing a 
complaint as any in surgery, and too often as little 
within the power of having its symptoms relieved ; 
the pain however, fortunately, in general, gradually 
abates, being too violent for the parts or constitu- 
tion long to bear* 

When in this state, the pain is not constant, but 
comes on in fits, usually in the evening or in the 
night, and at those times is extremely violent, and 
attended by spasmodi c contractions or convulsive 
motions of the limb, which sometimes extend to dif- 
ferent parts of the body. 

This symptom arises from the irritation being 
communicated along the course of the nerves, pro- 
ducing an action in these chords, attended with 
violent contractions in the muscles which they sup- 
Pty- 

To enter more fully into an explanation of this ac- 
tion of the nervous chords at present, would break 
in too much upon the general view of the different 
symptoms met with in this species of ulcer now un- 
der consideration ; it will therefore be reserved for 
another chapter. 



ACTIONS ARE TOO VIOLENT* 101 

When the marks above mentioned are not pre- 
sent, which very often happens, we are frequently 
led to a knowledge of the disposition of the ulcer by 
the previous history of the case, and the effects ot 
different medicines that have been used : but where 
there is no such history to be obtained, and the ap- 
pearance leaves us in doubt, it is prudent always at 
first to take up the treatment under the idea that the 
ulcer is irritable ; as it is an error, where we are 
wrong, of the least consequence, and where right, 
we have a considerable advantage, in not only hav- 
ing gained the whole time of the experiment, but in 
having saved the patient from a great deal of unne- 
cessary pain. 

When an ulcer takes place immediately over the 
projecting part of the fibula, which forms the outer 
ankle, it commonly puts on the appearance of an ir- 
ritable ulcer. This seems to arise from the nature 
of that part of the limb on which it is situated, inde- 
pendently of any constitutional or local disposition 
for irritability. It is probable that the periosteum, 
which at this part lies immediately under the skin, 
becomes the seat of the ulcer, which renders it very 
difficult to heal, and gives it this particular appear- 
ance. I was led for some years to suspect, that, in 
all such instances, the bone was injured, from hav- 
ing found that to be the case in several very tedious 
I 2 



102 OF ULCERS IN PARTS WHOSE 

ulcers in this part ; but have since seen many re- 
cover, although very slowly, without the bone being 
exposed : and therefore conclude, that the difficulty 
attending the cure, which is almost always found, 
does not necessarily depend upon the state of the 

bone. 

w 

This opinion is further strengthened by many ul- 
cers situated upon the ligament of the patella, and on 
the periosteum of the anterior surface of the tibia 
putting on a similar appearance, and being equally 
tedious in the cure. 

The great object to be kept in view, with regard 
to the management of ulcers, is that of ascertaining 
with accuracy their true nature. Too much atten- 
tion cannot be paid to this investigation. When it 
is completed, if the ulcer is ascertained to be of the 
irritable species, little difficulty will remain. All 
that is wanted will be to find out what particular se- 
dative application may be best suited to the case un- 
der our care, and the form in which it can be used to 
the greatest advantage. 

That ulcers are rendered irritable, whenever the 
actions of the constitution are increased beyond what 
is necessary for health, cannot be better illustrated, 
than by stating what has frequently happened on 



ACTIONS ARE TOO VIOLENT, 103 

board the Fleet during the present war. Ulcers 
have become, in many ships, so general, that it ap- 
peared to be an infectious disease spreading by con- 
tagion ; the smallest scratch, even the orifice made 
by a clean lancet in bleeding, degenerating into an 
irritable ulcer, and spreading to a considerable ex- 
tent, not running along the skin, nor indeed so rea- 
dily affecting the skin as the deeper seated parts, the 
principal mischief being committed upon the cellular 
membrane, muscles, tendons, and ligaments, the dis- 
charge thin and ichorous, no appearance of granula- 
tions, and when the tendons were exposed, nervous 
twitchings taking place in the muscles. 

It would stem difficult to account for so very sin- 
gular a disease pervading a ship's company, at least 
that the constitutions of the men should be so gene- 
rally indisposed, that a breach of the integuments 
immediately degenerated into such an ulcer ; but it 
appeared to Dr. Baird, the Physician to the Baltic 
Fleet, that in the ships, on board of which this took 
place, the men had been taken suddenly from a 
spare diet to a generous one ; and that the mode of 
treatment most effectual in his practice was, redu- 
cing their general strength by every means, as bleed- 
ing, purging, and giving large doses of the citric 
acid, at the same time giving opium liberally ; but 
where the strengthening plan was adopted, they not 



104 OF ULCERS IN PARTS WHOSE 

unfrequently were obliged to have their limbs am- 
putated. 

The only rational mode in which this appears t© 
me to admit of explanation is, that the mens' bodies, 
in a debilitated state v were too suddenly overloaded 
by supplies of nourishment, which excited great 
action in the heart and arteries, and hurried on the 
circulation in these weakened parts, next the extremi- 
ties j and when an injury had been committed on 
them, this violent action in the smaller vessels, instead 
of restoring what was lost, produced ulceration. 
This is exactly similar to the effects of warmth to 
a part which has been frostbitten: in a part so 
weakened, the action is too great, and mortification 
ensues, but snow, or very cold water, would have 
allowed the part to recover. In the one case, the 
violent action is constitutional, in the other, it is 
local. It is upon the same principle that a fever, 
when it attacks a person who has a common healthy 
ulcer, shall make it worse, but if it is an indolent 
one, shall effect a cure. 

The variety which occurs among constitutions 
has been already noticed, and we find that its 
influence produces a similar variety in the disposi- 
tions of ulcers. It will therefore be necessary 
to have a number of different medicines, which 



ACTIONS ARE TOO VIOLENT. 105 

may be used in different forms, and of different 
degrees of strength, so as to adapt them to the 
peculiarities of particular cases, even of the same 
species of ulcer. It is this circumstance which 
gives the surgeon, who has the most extensive 
knowledge of the effects of different external ap- 
plications, a material advantage ; since having greater 
resources within himself, he will be able to vary his 
medicines, and will ultimately succeed, where 
another, whose practice had been limited to a few 
applications, would have failed of success. The 
young surgeon should therefore spare no pains in 
storing his mind with as extensive a stock as 
possible of this kind of knowledge. 

There is a very curious fact respecting the treat- 
ment of ulcers, which makes this extensive experience 
of the medicines which are applicable to them still 
more necessary : it is, that very few cases will con- 
tinue to heal, more than for a certain time, under 
the same treatment ; the effect which any one ap- 
plication produced at first being lost by habit, so 
that it becomes necessary to change it for some 
other. This change of treatment, after a certain 
continuance, is so necessary, that even where the 
transition is made from a medicine with considera- 
ble powers, tcrone, which, had it been originally ap- 
plied, would have had little or no effect, will be 



106 «F ULCERS IN PARTS WHOSE 

productive of an evident advantage. This, how- 
ever, will be of short continuance ; but if the change 
is made to a medicine of equal, or nearly equal, 
powers, the benefit will be more permanent. 

This fact corresponds with what is stated to hap- 
pen in the practice of medicine, in many diseases 
of the system, both with respect to internal medi- 
cines, and external circumstances. A change of air 
is often found to be necessary, not from a worse to a 
better, but because the patient has continued too 
long in the same air, so that it is simply a change 
that is wanted ; and benefit would be derived from 
it, even if it were made from a purer air to one of 
less salubrious qualities. 



APPLICATIONS CONSIDERED WITH REFERENCE TO 
THIS SPECIES OS ULCER. 

It will be proper to state the different applica- 
tions suited to this species of ulcer ; leaving it to the 
judgment of the practitioner to select such as may 
be adapted to the peculiarities of the cases which 
are entrusted to his care. 

1. In the form of vapour. 



ACTIONS ARE TOO VIOLENT. lO? 

Medicines in this form are more immediately ap- 
plicable to irritable ulcers, than to any others, since 
warmth very generally allays irritation, and soothes 
the sensations of the patient. 

The vapour of common water, from its degree 
of heat, is very soothing to many ulcers in an irri- 
table state ; it is, however, very seldom used by it- 
self, but united with other substances, which either 
have, or are supposed to have, some sedative quali- 
ty. 

The vapour of spirits mixed with that of water 
adds to its powers of allaying irritation. 

Opium is used with advantage, as a fomentation 
in different forms : such as the tincture of opium 
sprinkled on flannels wrung out of hot water ; the 
extract of opium dissolved in hot water; or a decoc- 
tion of poppy-heads, heated, and applied by means 
of flannels. 

Chamomile flowers infused in hot water ; the tops 
of wormwood boiled so as to form a decoction ; and 
the fresh or dried leaves of hemlock boiled into 
strong decoctions ; are also used as fomentations. 
The extract of hemlock, and extract of opium, dis- 



108 OF ULCERS IN PARTS WHOSE 

solved in hot water, make a very useful liquor for 
fomenting, where there is much irritability. 

The great disadvantage attending the use of fo- 
mentations is, the short time they can be conveni- 
ently applied at any one time ; but their beneficial 
effects in many instances remain for hours after they 
have been used. 

There are cases of irritable ulcers which are ren- 
dered more painful by the application of any thing 
warm. In such ulcers there is generally a disco- 
loration upon the limb, of a mottled, purplish ap- 
pearance, for some way from the ulcer ; the lower 
part of the leg is also unusually cold. When that 
is the case, fomentations ought not to be used. It 
will often be found, in those instances, that there is 
a tendency to mortification, the parts being extreme- 
ly weak, as well as irritable, and scarcely able to 
support themselves in their present state, so that the 
action excited by the warmth hurries on the ulcera- 
tion of the weakest parts, or produces mortification, 
both of which processes are attended with pain. 

2. In a moist state. 

The most simple application in this form is the com- 
mon poultice, which may be made with bread and 



ACTIONS ARE TOO VIOLENT. 109 

water, with a little sweet oil, or hog's lard, or bread 
and milk. Water is often preferred, as the milk 
very soon becomes offensive to the smell. There 
does, however, as far as the evidence of patients can 
be relied on, appear to be some soothing property 
in milk, since the parts are easier in many instances 
under a poultice of that kind, than one made either 
with water or decoction of poppies. Linseed meal 
has some advantages over bread in forming a poul- 
tice ; it does not require oil, which is found often 
to disagree with an ulcer, it has a degree of tenacity, 
and can therefore be kept more immediately on the 
part, and it is more readily removed. It is also 
sooner made, all that is necessary being the pouring 
boiling water on the meal, after which the poultice 
is immediately fit for application. A mixture of 
bread and linseed meal in different proportions, 
makes a very good poultice, and is in many instan- 
ces preferable to the linseed meal alone. 

The extract of lead dissolved in water has been 
much recommended as an application in form of 
poultice ; and in many cases it answers very well, 
but in a great variety of instances it does not agree 
with the parts ; and when long applied, it has been 
known to bring on the lead cholic. It should there- 
fore be used with caution. Lead applied to ulcers, 
in patients whose constitutions are very irritable, 



110 OF ULCERS IN PARTS WHOSE 

very often disagrees, and not only irritates the sur- 
face to which it is applied, but is either absorbed 
or affects the extremities of the absorbents, so that 
they inflame, and the glands through which they 
pass become swelled : of this effect several instan- 
ces have come under my care, in which, upon leav- 
ing off the lead, the symptoms have subsided. 

This is the more deserving of attention, as we 
are in general unwilling to attribute the unfavoura- 
ble changes any disease takes, to the mode of treat- 
ment, which, however, is not unfrequently the case. 
The following instance is of this kind. 

A gentleman about 60 years of age had an acci- 
dent by which he broke his shin, to the hurt part he 
applied a solution of Goulard's extract of lead ; this 
was on the 4th of October, 1798. Impatient of con- 
finement, he increased the strength of the solution, 
but the small slough formed by the accident had not 
separated on the 8th of November ; it was not a 
quarter of an inch in diameter ; the lymphatics of 
the leg and thigh, had become painful ; the leg and 
foot were cold, and the glands between the thigh and 
groin had swelled, and threatened suppuration. In 
this state I saw him, and attributed all these effects 
to the solution of lead ; it was immediately left off, 
the glands in the groin, and the small ulcer on the 



ACTIONS ARE TOO VIOLENT. Ill 

leg, were bathed with equal proportions of decoc- 
tion of poppies and chamomile flowers : in two days 
the slough separated, and in four the glands subsid- 
ed, and the ulcer healed under the use of powdered 
rhubarb. Spirituous applications had disagreed 
with his skin upon former occasions, which led him to 
use the solution of Goulard's extract of lead ; and 
when much diluted, any hurt to which it had been 
applied got well, but in this instance, it had been 
made too strong, and had acted as a violent cause of 
irritation. 

Decoction of poppy-heads makes a very useful 
liquor for a poultice ; this also disagrees in some 
instances, but less frequently with irritable ulcers, 
than the preparations of lead. 

Carrots grated, and beaten into a pulp form a 
substance which in its consistence makes a very 
good poultice, and, from the properties of the car- 
rot, is well adapted to irritable ulcers ; many of 
them healing more readily under its use than by 
any other mode of treatment. It is curious to ob- 
serve w r hat slight circumstances make a material 
difference in the effects of a medicine upon an ulcer. 
In a particular instance of an irritable ulcer, which 
had been under the care of several different surge- 
ons, and to which a variety of applications had been 



112 OF ULCERS IN PARTS WHOSE 

made, every thing that was tried disagreed with it, 
except the carrot poultice ; even this, made in the 
manner above mentioned, did not give it the least 
disposition to heal. It was therefore proposed that 
the carrots should be boiled and beaten into a pulp, 
before they were applied, the pain was immediately 
diminished, and the ulcer healed by a continuance 
of that application. 

As the greatest objection to poultices, in most 
cases of this kind, is their weight, it becomes an 
object of attention, wherever it can be done, to let 
the limb rest upon the poultice, and not the poul- 
tice upon the limb ; when this cannot be managed, 
and the weight of its application gives pain and un- 
easiness, so as more than to counterbalance its be- 
neficial effects, it will be better to change it for some 
lighter application. 

Where poultices agree, it is a matter of some 
consequence to determine how long their use should 
be continued. This will depend principally on the 
appearance of the granulations ; if they are small, 
and the ulcer is rapidly diminishing in size, no 
change should be made till the cure is completed y 
but if the granulations are become large and looser 
in texture, it appears proper to leave off the poultice, 
even where the ulcer is evidently contracting. 



ACTIONS ARE TOO VIOLENT. 113 

It is proper to mention that many irritable ulcers 
will begin to heal before they put on a healthy ap- 
pearance ; and after they have skinned over to a 
considerable extent, the remaining ulcer shall still 
have a foul appearance ; while this is the case, the 
poultice should, I believe, always be continued. 

Where poultices cannot be used, in consequence 
of their weight being more than the parts can bear, 
one of the following solutions may be applied upon 
lint: extract of opium dissolved in water, decoction 
of poppies ; tincture of opium ; decoction of cicuta; 
aqua lythargyri acetati composita ; solution of ar- 
gentum nitratum, in a diluted state. The best mode 
of using these medicines would probably be keep- 
ing the parts constantly moist, by renewing the ap- 
plication as often as it became dry ; but as this 
would be attended with a great deal of trouble, it 
cannot be pursued as a general practice ; and a 
pledget of white ointment over the dressing pre- 
vents the lint from drying and sticking to the sur- 
face of the ulcer. 

3. In a dry form. 

For ulcers of this species there are few medicines 
in form of powder that are sufficiently mild in their 
properties to admit of being employed. 
k 2 



114 OF ULCERS IN PARTS WHOSE 

The carbon has been lately introduced into prac- 
tice, and by some practitioners highly extolled. 
From wliat experience I have had of it, it appears 
to be an useful medicine, in many cases of irritable 
ulcers ; having found it to agree where other more 
common applications have failed. It has this dis- 
advantage, that its colour prevents the surface of 
the ulcer from being distinctly seen at each dress- 
ing ; and any attempt to wipe it clean gives pain, 
and irritates the granulations. 

The extract of opium, in the form of powder, 
mixed with the carbon, in equal proportions, or 
with any other powder, as the linseed flour, is an 
useful application. It is a circumstance deserving 
of observation, that in some cases the opium is ab- 
sorbed in sufficient quantity to affect the system, 
and produce sleepiness. When this happens, it is 
difficult to determine whether the benefit arises from 
the immediate action produced on the ulcer, or the 
effect the opium has upon the system. 

Opium, externally applied, sometimes gives pain, 
and when that happens, it generally aggravates the 
other symptoms. 

The extract of opium in some cases appears to act 
as a poison, producing the most violent effects of in- 



ACTIONS ARE TOO VIOLENT. 115 

flammation, which terminate in mortification ; these 
however, are rarely met with ; the possibility of such 
an effect taking place becomes a strong reason against 
the application of opium in so concentrated a form, 
where there is a great degree of irritability in the 
parts. 

The following observations made by Mr. Adair, 
while surgeon to Chelsea Hospital, on the use of 
opium to ulcers, has been communicated to me by 
Dr. Heberden, who found them among his father's 
papers, to whom they must have been given by Mr. 
Adair ; they confirm in the strongest manner the 
above-mentioned circumstances in favour of the lo- 
cal use of that medicine. 

" In Chelsea Hospital there are many old ulcers 
of the legs, which frequently, in a short space of time, 
increase in size, and become very painful, and trou- 
blesome to manage. 

" In April and May, 1780, several of these ulcers, 
which had increased in size, and become very pain- 
ful, were dressed with lint, dipped in a solution of 
opium in water (in the proportion of an ounce of the 
extractum thebacium, to a pint of water) at the same 
time, some ulcers in the same state, were dressed 
with a poultice of bread, into which half an ounce of 



116 OF ULCERS IN PARTS WHOSE 

the above solution was put : in all these cases, im- 
mediate ease and sound sleep, were procured ; (al- 
though to most of these patients opium had been 
previously given by the mouth, and had not procur- 
ed them sleep ;) and they remained drowsy through 
the day: on continuing these applications a few 
days, repeating them night and morning, some pa- 
tients complained of pain in the head, with dimness 
of sight ; others of sickness, diarrhoea and pain in the 
bowels ; in all their sleep was disturbed ; and the 
discharge from all their ulcers was much lessened. 
Those patients, who were treated with the solution 
in the poultice, neither felt these complaints so early, 
nor so violently, as those who were dressed with lint 
dipped in the solution. In all these patients, on 
leaving off the use of the solution, their complaints 
disappeared, and the discharge from their ulcers re- 
turned as before. 

" On December 23d, 1780, two patients were af- 
fected with the same painful kind of ulcers, and 
were dressed with lint, dipped in a solution of 
opium in water, much weaker than the former (a 
dram of extractum thebacium to a point of water.) 
On the 25th, the first patient was attacked with pain 
in his bowels, and a slight purging. 26th. His 
complaints were increased, and he complained also 
of pain in his head, and giddiness ; the solution was 



ACTIONS ARE TOO VIOLENT. 117 

left off this day, and his complaints went away gra- 
dually. The second patient did not make any com- 
plaints, before the 26th, when his bowels were unea- 
sy, and he was affected with giddiness, and dimness 
of sight : the solution was now applied only once a 
day. 29th. His symptoms having increased, the 
solution was left off entirely, and his complaints left 
him : in both these cases ease was procured on the 
application of the solution, as in the others ; in both, 
the discharge from the ulcers was diminished, and 
increased again on leaving it off." 

4. In an unctuous form. 

This form of application is not well adapted to the 
generality of irritable ulcers, for the following rea- 
sons. The oil or lard, which makes a part of the 
preparation, is generally rendered more or less ran- 
cid, as has been already noticed, by the process of 
forming the ointment, which is commonly by means 
of heat. It also happens, that the skin of persons 
whose habits are irritable, and who are therefore 
most liable to ulcers of an irritable nature 2 frequent- 
ly will not bear the application of common ointment. 
Under such circumstances very few unctuous dress- 
ings can be used. 



118 OF ULCERS IN PARTS WHOSE 

In some cases of irritable ulcers, cream, where it 
can be procured, is often a very soothing application ; 
the cases in which it answers best are where the 
parts cannot bear warmth, the pain being increased 
by it ; there is a coldness in the cream, which in 
such instances considerably mitigates the painful 
sensations. 

As a substitute for cream the following ointment 
is used with advantage : hog's lard purified by fre- 
quently washing it in spring water, and then made 
into an ointment, with a small portion of white wax 
and rose water. 

The unguentum cerussae acetatse agrees in some 
particular cases, but in many others it appears to do 
harm ; the same caution is therefore necessary here 
as when the solutions of lead are employed. 

These are the only ointments in general use that 
can be recommended in ulcers which belong to this 
class. 

5. Bandages. 

In this species of ulcer benefit will rarely be 
derived from compression. The surface of the 
ulcer is, in general, unable to bear any pressure 



ACTIONS ARE TOO VIOLENT. 119 

without being rendered more painful, and whatever 
gives pain proves in these cases injurious. The 
bandage employed should only be sufficiently tight 
to retain the dressings in their place ; nor should it 
even be more so, upon the other parts of the leg. 

It does happen that a tight bandage will bring 
on spasms which extend all the way up to the body, 
and when the compression is removed, they go off. 

In other cases where there is a less degree of 
irritability, and that arising from weakness, com- 
pression within certain limits may be used with the 
greatest benefit. 



In this species of ulcer it is very difficult to give 
any particular directions respecting those medicines 
that are to be tried in preference to others. 

Poultices are the safest to begin with, and when 
it shall be thought right to change the application, 
the surgeon will have acquired a degree of know- 
ledge of the disposition of the ulcer, and the pecu- 
liarities of the constitution, which will guide him 
in his future choice. 



120 OF ULCERS IN PARTS, &C. 

If the degree of irritability be very great, he will 
adopt those medicines which are the mildest in 
their nature, softest in their form, and can be used 
with the least pressure arising from their weight. 
Among these cream, or the ointment substituted 
for it, are probably the best applications. 

If the irritability is not great, but the parts little 
disposed to heal, the weak solution of the argentum 
nitratum is one of the best medicines. 



CHAPTER VI. 

EXPERIMENTS AND OBSERVATIONS ON THE IRRI- 
TABILITY OF NERVES, BY WHICH THE SPASMODIC 
AFFECTIONS ATTENDANT UPON IRRITABLE UL- 
CERS ARE ACCOUNTED FOR, 

X he nerves have been hitherto considered as 
chords that have no powers of contraction within 
themselves, but only serving as a medium, by means 
of which the influence of the brain may be commu- 
nicated to thje muscles, and the impressions made 
upon different parts of the body conveyed to the 
brain. # 

The difficulties which attend every attempt to in- 
vestigate the real state of the nerves in the living 
body, and the impossibility of acquiring any infor- 

* These observations on the irritability of nerves were laid 
before the Royal Society in November, 1800, and have a place 
in the Philosophical Transactions. 
L 



122 ON THE IRRITABILITY. 

mation upon this subject after death, may be urged 
in excuse for this opinion having been so universally 
received, since it will be found, from the following 
experiments and observations, to be void of found- 
dation. 

The only means by which any knowledge respect- 
ing the irritability of nerves can be procured, must 
be from the operations in surgery performed upon 
nerves, either in a healthy state, or under the influ- 
ence of disease ; or from experiments made upon 
animal bodies before they are wholly deprived of life, 
and instituted for that particular purpose. 

My attention was directed to this subject by the 
following case, which explains many circumstances 
respecting the actions of the nerves when under the 
influence of disease, and gave rise to the experi- 
ments and observations contained in this chapter. 

A person thirty-six years of age, naturally eager 
and anxious in his disposition, whose stomach was 
peculiarly irritable and irregular in its action, in the 
winter of the year 1796, while riding in the coun- 
try, was thrown from his seat by a sudden motion 
of the horse ; and in endeavouring to save himself, 
fell with his whole weight upon the end of his 
thumb, agaiast the pommel of the saddle. 



OF THE NERVOUS CHORDS. 123 

The part swelled, and became very painful. 
A few days after, he hurt it again, which prevented 
the swelling from subsiding, and it remained uneasy 
and enlarged for three or four months. It after- 
wards got well, but the motions of the thumb were 
not always under the command of the will ; so that 
he was sensible, in the years 1797 and 1798, while 
writing, of finding a difficulty in forming particular 
letters. 

On the evening of the 16th of October, 1799, 
which was cold and damp, he was travelling in a 
post-chaise with two other persons, and let down 
the window, to speak to the driver. A cold wind 
blew directly into the carriage, and he endeavoured 
to pull up the window ; but, not seeing the glass 
rise, he looked down, and his hand, instead of pull- 
ing up the window, was lying upon his knee. The 
thumb was bent in towards the palm of the hand ; 
a spasm came upon the muscles of the arm, making 
them bend the elbow ; and immediately he became in- 
sensible : in a quarter of an hour he perfectly recover- 
ed himself. Some hours after, upon his bending his 
thumb, to shew what had happened to him in the 
carriage, there was a return of the same attack, 
which also rendered him insensible for a few 
minutes. 



124 ON THE IRRITABILITY 

From this time, he had no return of these attacks 
for nine weeks ; at the end of which period, on the 
18th of December, 1799, he was waving his hand 
over his head, with a degree of eagerness, as a sign 
for some people to make haste and follow him ; this 
exertion made the thumb contract towards the palm 
of the hand, and he fell upon the ground in a state 
of insensibility. This attack went off as the others 
had done ; he had another in the evening ; and, in 
the course of the next day, two more, equally violent. 
As the motion of the thumb was the first symptom 
in all these attacks, the assistants were led to contrive 
a glove, the front of which was strong enough to 
resist the motion of the thumb, and to keep it in its 
place ; while this was kept on, the attacks were less 
frequent. A ligature was then applied round the 
fore-arm ; when the thumb was beginning to be 
agitated, this was tightened, and the spasms were 
found to be arrested at the ligature, and of course 
deprived of their violence. 

- From this time, a tourniquet was kept constantly 
upon the fore-arm ; and a person was always in 
readiness to tighten it, the moment the spasm was 
expected, which was always preceded by a general 
feel of uneasiness all over the body : as soon as 
the spasm went off, which it did instantaneously, 
the tourniquet was loosened. The spasms in the 



OF THE NERVOUS CHORDS, 125 

thumb and fore- arm returned frequently, and at 
irregular intervals, generally every three hours, 
sometimes oftener, and once did not come on for 
thirty-six hours. 

On the third or fourth day, electricity was tried, 
with a view to relieve them ; sparks drawn from the 
thumb, produced tremors in the muscles, which 
were confined to the thumb. An electric shock 
through the ball of the thumb, brought on a very 
severe spasm in the arm ; but neither sparks, nor 
a shock through the other thumb, produced any sen- 
sible effect. 

On the 29th of December, I first saw the patient ; 
and, after watching the symptoms for three days, 
made the following ovservations upon the com- 
plaint. 

That the beginning of the attack was some in- 
voluntary motion of the thumb and fore-finger ; and 
therefore, the disease appeared to be in the branch 
of the nerve which supplies these two parts, called 
by Winslow, the median nerve. 

That the progress of the spasms was in the direct 
course of the trunks of the median nerve, up to the 
head. 

l 2 



126 ON THE IRRITABILITY. 

That compressing the parts in the course of that 
nerve, when it was done before the spasms had 
reached them, always arrested their progress ; but, 
when once the muscles had become convulsed, or 
agitated, the same compression had no effect in stop- 
ping the progress of the spasms. 

The mode in which the spasms were propagated 
along the course of the nerves, was as follows. 

Five or six tremors took place in the flexors of 
the thumb and fore-finger ; then similar convulsive 
motions affected the muscles of the fore-arm ; soon 
after, the muscles of the arm were thrown into the 
same kind of action ; afterwards the pectoral mus- 
cle, and scaleni of the neck : the muscles of the lower 
jaw were probably in the same state, although their 
action was not within the notice of the by-standers. 
The head was pulled forcibly to that side, in quick 
successive motions, and in a second or two, the 
whole ceased ; the parts became tranquil, the insensi- 
bility went off, and the patient recovered himself : 
there was, however, a general feel of langour and 
distress over the whole body, before the recovery. 

From these observations, the disease appeared to 
be decidedly in the inferior branches of the median 
nerve ; and the irritation was conveyed along its 



Or THE NERVOUS CHORDS. 127 

course, from its terminations in the thumb and fore- 
finger, to the origin in the brain. 

It was proposed to divide the nerve, as it passes 
from under the annular ligament of the wrist towards 
the thumb, to cut off the communication between 
the diseased extremities and the trunk of the nerve, 
and so put a stop to the progress of the irritation 
which constituted the diease. 

That such an operation might be attended with 
success, was not only rendered probable from reason- 
ing, but the performing it was fully justified by the 
success which had been experienced from a similar 
operation, in some cases of the tic douloureux ; 
a disease, in many respects, of the same nature with 
the present. 

All these circumstances were explained to the 
patient, who from a desire of obtaining relief, con- 
sented to have the nerve divided. This was done 
on the first of January, 1800, in the following man- 
ner : the nerve, as it passes from under the annular 
ligament, towards the thumb and fore-finger, was 
laid bare, for above an inch in length : it was then 
detached from its lateral connections, and, in this 
exposed state, a probe-pointed bistoury was passed 
behind it, and the nerve was raised upon the edge 



128 ON THE IRRITABILITY 

of the instrument, so as to be distinctly seen by the 
different medical gentlemen present, before it was 
cut through. As soon as it was divided, the two 
cut ends retracted from one another, to a considera- 
ble distance. This retraction was very unexpected, 
as the nerve was disengaged from the cellular mem- 
brane, and no other part had been divided, whose 
action could make the portions of the nerve re- 
cede. 

That nerves, when divided, do retract, is well 
known in the practice of surgery ; but this effect 
has been usually attributed to the contraction of the 
neighbouring parts, as the cellular membrane and 
blood-vessels, with which the nerves are connected. 
As none of these causes could produce the effect in 
the present instance, it was natural to suppose, that 
an independent action existed in the nerve itself, 
which had been so much increased by the influence 
of disease, as to become unusually great ; and there- 
fore, the retraction was iriore distinctly seen than in 
a healthy state of the body. 

The moment the nerve was divided, there was a 
spasm over the whole body, and a momentary in- 
sensibility. The blood-vessels divided in the ope- 
ration were not secured by ligature, but allowed to 
stop of themselves, to give the wound every chance 



OF THE NERVOUS CHORDS. 129 

of healing by the first intention. The edges of the 
skin were carefully brought together, and kept in 
in that state by compress and bandage, to promote 
as much as possible the union. 

For eight hours after the operation, the parts 
were perfectly quiet, and there was no spasm. The 
wound then began to feel hot, as if a red hot coal 
had been applied to it. To relieve this sensation, 
the outer bandage was loosened, and immediately 
there were twitches in the nerve, which soon went 
off. The patient felt himself generally unwell, ex- 
tremely nervous, and irritable, 

Ffteen hours after the operation, he had a violent 
spasm, which went along the arm to the head, but 
did not affect the brain. In an hour there was a 
second attack, at which I was present ; the pulse 
was 105 in a minute, the tongue white, a great deal 
of general irritation, nervous twitches all over the 
body, but in the greatest degree in the arm and leg 
of that side. The stiff-fronted glove was now put 
on, to confine the thumb. 

Twenty-four hours, or one day, after the opera- 
tion, the first dressings were removed : the thumb 
was mucKswelled, and no union whatever had taken 



130 ON THE IRRITABILITY. 

place ; the spasms returned every five hours, but 
were less violent. 

The second day, there was no abatement of the 
symptoms, but the spasms did not affect the brain ; 
they were not now stopt by the pressure of the 
tourniquet, as they had been before the operation. 

The third day, there were intervals of ten hours 
between the spasms ; and, in the night, they did 
not extend beyond the elbow. 

The fifth day, suppuration took place in the 
wound ; the swelling in the hand was much abated ; 
and the patient was able to dress and shave without 
spasm, having only twitches in the fingers, and tre- 
mors in the fore-arm. 

The sixth day, there was a burning pain in the 
hand, and a numbed heavy feel in the thumb and 
fore-finger, similar to f what the patient recollected 
to have felt four years before, when he hurt his 
thumb. 

The seventh day, the patient awoke with great 
pain in the hand, succeeded by a violent spasm, 
which passed up to the head, although the tourni- 



OF THE NERVOtTS CHORDS. 131 

quet had been previously tightened : after this, he 
had no spasm for sixteen hours. 

The eighth day, the hand was less swoln and less 
painful ; and he had oaly two spasms in twenty- 
four hours. 

r . The ninth day, the swelling had subsided, and the 
twitches ceased ; in thirty hours, there was only one 
slight spasm, which did not go beyond the wrist. 

The sixteenth day, the wound was entirely heal- 
ed ; and, as there had been no return of spasms, the 
patient was considered as well. 

On the twenty- fourth day, which was a fortnight 
after the spasms had ceased, at nine o'clock in the 
morning, he was awakened by a violent spasm, 
which passed directly up to the head, and affected 
the brain, producing insensibility ; this was the on- 
ly time the brain had been affected since the opera- 
tion. 

Two days previous to this attack, he had a vio- 
lent diarrhoea ; and, on the preceding day, had un- 
dergone unusual fatigue. 



132 ON THE IRRITABILITY 

The tourniquet which had been laid aside, was 
now applied ; and, for the greater security, two 
were placed on the fore-arm, and one upon the arm 
itself. At six in the evening, there was another 
spasm, attended by insensibility, although the tour- 
niquets had been tightened. The hand was found 
swoln, as well as the wrist, and the cicatrix formed 
a hard welt, tender to the touch. This hard state 
of the cicatrix, in which the end of the divided nerve 
was included, appeared to be a probable cause of the 
return of the spasmodic attacks. 

The twenty-fifth day, the pulse was 100 in a 
minute; and, every two hours, there were slight 
spasms. 

The twenty-sixth day, there were eleven spasms 
at irregular intervals, in twenty-four hours, eight of 
which, went up as high as the head. As the spasms 
were not stopped by the tourniquet, as before, it 
was proposed to make the pressure directly upon 
the nerve : this was done by placing pieces of cork 
in the course of the nerve, and confining them there 
by the band of the tourniquet, so that, when the 
screw was tightened, the cork was pressed down on 
the nerve. This pressure gave great pain, and, in- 
stead of arresting the progress of the spasms, seem- 



OF THE NERVOUS CHORDS* 133 

ed rather to increase their violence ; it was there- 
fore left off. 

The twenty-seventh day, the pulse was only be- 
tween 80 and 90 in a minute ; there were seven 
spasms, all of which were arrested by the first or se- 
cond tourniquet. 

The spasms went on with very little variation, till 
the 39th day at six o'clock in the morning, when he 
was seized in his sleep with a violent spasm, attend- 
ed with insensibility, and convulsions over the whole 
body : these lasted for twenty minutes. After his 
recovery, the hand was found much swoln, and the 
welt formed by the cicatrix was painful. In the 
course of the forenoon he was well enough to bear 
going out in the carriage ; the fresh air always prov- ' 
ing very grateful to him. 

From this time, the swelling of the hand and the 
hardness of the w T elt diminished ; and the spasms 
were less violent, and seldomer. On the 45th day, 
there was only one slight spasm in twenty-six hours . 
In this state he went into the country ; and, for the 
first fortnight, the spasms diminished, but after- 
wards became more violent. 



M 



134 ON THE IRRITABILITY 

The return of the spasms, after the wound had 
been healed, made it evident, that the operation of 
dividing the nerve had not answered the purpose 
which was expected from it. The failure probably 
arose from the wound not healing by the first inten- 
tion : the consequent inflammation rendered the cut 
end of the nerve uncommonly irritable ; and, in this 
state, the confinement in the hard thickened cicatrix 
rendered it liable to be stretched by every motion of 
the thumb, so as to bring on spasmodic contrac- 
tions. 

From this time, the patient was not under my di- 
rection ; but I understood, that he tried the effect 
of large doses of opium, which did not afford relief. 
He was then induced to employ electricity, which 
was also unsuccessful ; and he died in a fit, which 
at the time was believed to be apoplexy, about five 
months after the operation had been performed ; 
but, as the bodv was not examined, the nature of the 
fit could not be ascertained. 

In this case, some of the branches of the median 
nerve had acquired, from disease, an unnatural pow- 
er of contraction, which was made evident by the 
operation ; and there is every reason to believe, that 
the spasmodic attacks which took place were in 
reality convulsive motions in the nerves themselves, 



OF THE NERVOUS CHORDS. 135 

which excited corresponding contractions in those 
muscles that were under their influence. 

This case naturally occupied my mind; and I 
could not avoid dwelling upon many of the extraor- 
dinary symptoms which made a part of it ; but no- 
thing so impressed itself upon me, as the retraction 
that took place in the cut ends of the nerve, at the 
time of the operation. 

The first idea which suggested itself was, to en- 
deavour to ascertain whether this retraction arose 
from an increase of a natural action in the nerve, or 
from one newly acquired, produced by disease, 

With a view to ascertain this point, different ex- 
periments were instituted. The object of these was, 
to determine whether a similar contraction took 
place in nerves, when divided in a healthy state of 
the body ; the extent of such contraction, if any oc- 
curred ; and the circumstances by which it may be 
influenced. 

For the first of these purposes, the following ex- 
periments were made. 

Exper. 1. The cutaneus internus nerve of the 
fore-leg of a young rabbit was laid bare, where it 



136 ON THE IRRITABILITY 

passes down before the biceps flexor cubiti muscle ; 
the nerve was disengaged from its lateral attach- 
ments ; and, while the limb was in a moderately 
extended state, a probe-pointed bistoury was passed 
behind it, by which means it was divided transverse- 
ly. The two ends immediately receded from each 
other : the upper portion appeared to retract more 
than the other, and the end lay close to the muscle, 
in a straight line, while the end of the lower portion 
was a little bent to one side. The space between 
them, when measured by a pair of compasses, was 
found to be | of an inch. 

The branch of the musculo- cutaneus nerve, which 
lies near to the cutaneus internus, was divided in the 
same manner; and the retraction of the cut ends 
was found to have been to the same extent. 

In this experiment the limb was extended, al- 
though by no means to its utmost limits ; it there- 
fore became a question, whether the same degree of 
retraction would take place in the bent state of the 
limb. 

To determine this point, the experiment was re- 
peated, after an interval of four days, upon the other 
fore-leg of the same rabbit, with the limb in the bent 



OF THE NERVOUS CHORDS. 137 

state: the retraction, however, was found to have 
been exactly to the extent of f of an inch. 

From this experiment, made under these dif- 
ferent circumstances, a retraction of the cut ends of 
a divided nerve was ascertained to take place, which 
led to the further prosecution of the inquiry. 

For this purpose, the phrenic nerve in the horse 
was selected, as being more favourable, in many 
respects, than most others in the body, both from 
its superficial situation in the chest, and its great 
extent without giving off any branches. 

In making experiments of this nature, it is an 
advantage that the animal should be of a large size ; 
and the mode in which horses are killed in London 
affords an opportunity of experiments being made 
on that animal, without giving the operator the 
painful sensations of having made any addition to 
its sufferings. 

As horses are killed at stated times only, and 
these occur in a part of the day which is necessarily 
occupied by my professional engagements, the fol- 
lowing experiments were made by Mr. Clift, the 
Conservator of the Hunterian Museum, whose 
accuracy may be relied upon, as well as his abilities 
in conducting them, having been early initiated, 
and long experienced, in inquiries of this nature, 

M 2 



138 ON THE IRRITABILITY 

Exper. 2. Immediately upon a horse having 
been knocked down, the thorax was laid open, and 
the phrenic nerve of the right side, passing round 
the pericardium, was exposed. It was nearly of the 
size of a crow-quill, and slightly connected with 
the pericardium. In this state, the point of one 
blade of a pair of scissars was passed under the 
nerve ; and, by closing them, the nerve was trans- 
versely divided, without the smallest disturbance to 
its lateral connections. The two cut ends immedi- 
ately retracted from each other, leaving the space 
of one inch between their extremities. 

This experiment was repeated upon a second 
horse ; and the retraction of the cut ends of the 
nerve was found to be exactly one inch. 

It was repeated upon a third horse; and the 
retraction was found to be nearly two inches. In 
measuring the space between the two ends of the 
nerve, the compasses accidentally touched the lower 
portion, and the diaphragm was immediately thrown 
into action. 

The result of this experiment not only confirmed 
the former, which had been made upon the rabbit, 
but it proved, in the most satisfactory manner, that 
anv action the nerves are capable of exciting is 



OF THE NERVOUS CHORDS. 139 

nearly as strong after apparent death has taken place, 
from a violence committed upon the brain, as while 
the animal is in perfect health. 

Monsieur Portal, in a paper on a new mode of 
performing the operation of amputation, published 
in the Memoires of the Academy of Sciences for 
the year 1773, mentions an experiment made on the 
sciatic nerve of a dog, in proof of nerves not having 
a power of retraction, at least none deserving of 
notice.* 1 

This experiment was repeated by Mr. Clift, on 
the sciatic nerve of a rabbit. Immediately on 
dividing the nerve, the cut ends receded from one 
another : but, that the result might be exactly ascer- 
tained, the rabbit was killed half an hour after the 
experiment was made ; the parts were carefully dis- 
sected, and the space between the two cut ends 
measured ; which was exactly ^ of an inch. 

To ascertain whether this retraction was the 
consequence of a change taking place in the nerve 
itself, or arose from any other cause, the following 
experiment was made. 

* Memoire sur une nouvelle Methode de pratiquer P 
Amputation des Extremites, par M. Portal. 

Histoire de V Academic des Sciences, 1773. p. 542, 



140 ON THE IRRITABILITY 

Exper. 3. As soon as a horse was knocked 
down, the chest was laid open, and the phrenic nerve 
of the right side was exposed : twelve inches in 
length were immediately measured by a pair of 
compasses ; and the limits of this portion were 
marked by a small pin, passed transversely through 
the substance of the nerve. The part included 
between the two pins was then separated from the 
rest of the nerve, in the following manner. The 
person who was to divide the nerve had a pair of 
scissars in each hand ; and having passed the point 
of one of the blades under the nerve, above the up- 
per pin, and having done the same with the blade 
of the other pair of scissars, below the lower pin, 
the two pair of scissars were shut at the same 
moment, and the nerve at these two parts cut 
through. 

This portion was again measured, and, instead 
of being twelve inches, was now only eleven and j. ; 
so that the irritation produced by dividing it had 
made it contract |- of an inch. 

This experiment was repeated upon several hor- 
ses ; and in all these repetitions there was a con- 
traction produced : this varied in the different ex- 
periments, and in some of them was only| ths of 
an inch. When the nerve was divided very early 



OF THE NERVOUS CHORDS. 141 

after the animal had been knocked down, it was the 
greatest ; and, in proportion to the delay that took 
place, so was the diminution in the degree of the 
contraction. 

In these experiments, the nerve, as well as the 
surrounding parts, was disturbed as little as possi- 
ble, that the results might be the more readily and 
more accurately ascertained : this, however, makes 
them liable to an objection, which is, that the con- 
traction might be produced by the cellular mem 
brane surrounding the nerve ; an objection which 
certainly can have little weight in the peculiar situa- 
tion of the phrenic nerve, as it lies between the pleura 
and pericardium, where the cellular membrane can 
have little influence over it, while the pericardium 
is left entire. 

As, however, the opinion of the cellular mem- 
brane being the agent, by which the retraction of di- 
vided nerves is produced, has been very generally 
received, it was highly proper to attend to that cir- 
cumstance, and have the experiment made in such 
a way as to prevent any other surrounding part 
from acting upon the nerve ; with this view, the 
following experiment was made. 

Exper. 4. The pleura was removed from twelve 



142 ON THE IRRITABILITY 

inches of the phrenic nerve of a horse ; and after- 
wards the attachments between the nerve and peri- 
cardium were completely divided : under these cir- 
cumstances, this portion of nerve was separated, as 
in the last experiment. This portion was again 
measured, three hours after, in its detached state, 
and it was found to have lost f of an inch in length* 
The horse was twenty years old, and was killed 
on account of its age, which rendered it by no means 
a favourable subject for such an experiment. 

With a view to determine whether the power of 
contraction in a nerve continued for any length of 
time after apparent death had taken place, and also 
to ascertain what proportion of elasticity a nerve 
possesses (for every part of an animal body that is 
not rigid appears, to be endowed with it in a greater 
or less degree) the following experiment was made. 

Exper. 5. Eighteen inches in length of the phre- 
nic nerve were measured, and separated by means 
of scissars : the contraction produced was only f of 
an inch ; the experiment being made nearly an hour 
after the horse was knocked down. Upon being 
stretched with force, it elongated to 1 8^ inches ; 
and, on being left to itself, retracted to 17|-. It was 
kept till next day, and again measured, when it was 



or THE NERVOUS CHORDS. 143 

only lTf : upon being stretched, it was elongated 
to 18^; but, immediately on being left to itself, it 
retracted to 18 inches. 

This experiment was repeated vipon another 
horse ; and the result was similar, both with respect 
to contraction which took place after the nerve had 
been removed from the body, and the elongation 
which depended upon elasticity. 

To ascertain if there was any difference in the ap- 
pearance of a nerve when contracted, from one in 
a relaxed state, the following comparison was 
made. 

Exper. 6. A portion of the phrenic nerve, about 
eight inches long, was removed immediately after 
the horse had been knocked down. This was al- 
lowed to contract ; and after it had remained quiet 
for twenty-four hours, its external surface was ex- 
posed by dissection, so that the appearance of its 
fibres could be distinctly seen. A portion of the 
same length was removed from another horse who 
died a natural death, and these were compared to- 
gether. 

The difference in the appearance of these two 
portions was very great : in the contracted nerve, 



144 ON THE IRRITABILITY 

the fibres were all serpentine ; in the other they were 
straight. 

The serpentine transverse lines described by Mon- 
ro appear to be an effect of this contraction of the 
nerve ; as they disappear when the nerve is relaxed 
or elongated.* These serpentine lines in the phrenic 
nerve, in a man who died of a locked jaw, when 
examined twenty-four hours after death, were much 
'more distinct and regular than in the phrenic nerve 
of a man who died of a mortification of his arm. 

These experiments, upon so large an animal as 
the horse, made by a person well qualified for the 
purpose, and repeated sufficiently often to preclude 
any material fallacy, admit of the following conclu- 
sions being drawn from them. 

* " When the nerve is fully relaxed, these serpentine trans- 
verse lines are best seen ; when the nerve is moderately 
stretched, they are much less evident ; when the nerve is great- 
ly stretched, beyond what it ever is in a living sound animal, 
it appears uniform in its colour and consistence. Hence these 
lines, are in the Jirst place, to be considered as folds or joints 
in the nerve, and may be compared to the lines in the palm of 
the hand, serving to accommodate the nerve to the different 
states of flexion and extension." (In a note) u By soaking 
in water, this appearance is lost." 

Monro on the Nervous System, p. 39. 



OF THE NERVOUS CHORDS. 145 

1. That the nerves of an animal in health are ca- 
pable of retracting themselves when divided ; and 
that this effect is entirely independent of the parts 
by which they are surrounded. 

2. That this contraction takes place in the ner- 
vous fibres themselves ; and is independent of the 
brain, from which they originate, and of the mus- 
cles and other parts, in which they terminate. 

3. That the contracted nerve exhibits to the eye 
an appearance of contraction in its fibres, not to be 
seen when it is in a relaxed state. 

As the nerves are so readily influenced by elec- 
tricity, in exciting the muscles to action, it natu- 
rally suggested itself, that some further informa- 
tion might be obtained in the present investigation, 
by means of experiments made upon the nerves by 
the electric fluid. With this view, the following 
experiments were instituted ; and Mr. Carpue very 
obligingly assisted Mr. Clift in making them, and 
carried one of Mr. Cuthbertson's large plate-glass 
electrical machines to the slaughter-house for that 
purpose. 

Exper. 7. A portion of the phrenic nerve, twelve 
inches long, was exposed and divided at both end?, 

N 



146 ON THE IRRITABILITY 

as in the former experiments. When it had con- 
tracted to 11 1, a strong electric shock was passed 
along its substance, from one end to the other; but, 
when measured again, the length was exactly the 
same. The portion of nerve was then dissected 
out, and laid upon a piece of glass ; in its detached 
state, it measured llf. Several strong electric 
shocks were passed through it, in the direction of 
its fibres ; but they did not produce the smallest ef- 
fect upon it. 

This experiment was repeated upon another 
horse, and the result was the same. 

Exper. 8. Half an hour after a horse had been 
knocked down, 24 inches in length of the nerve 
called par vagum were laid bare, and a portion of 
it detached from its lateral connections, so that a 
piece of glass, 12 inches long, was admitted under 
it, without dividing the nerve from the trunk ; in 
this state, electric sparks were drawn from it, and 
several strong electric shocks passed through it ; 
but there was not the smallest change to be per- 
ceived, either in its length or appearance. 

From these experiments it appeared, that when 
the nerve had contracted itself, in consequence of 



OF THE NERVOUS CHORDS. 147 

being divided, no increase of that contraction was 
produced by the electric fluid. 

To ascertain whether electricity was capable of 
exciting contraction in a nerve that had not been 
previously irritated, the following experiment was 
made. 

Exper. 9. Twelve inches of the phrenic nerve 
were measured ; and the limits of that portion 
marked, by pins stuck through the nerve. This 
portion of nerve, in its relaxed undisturbed state, 
had electric shocks passed along its substance ; but 
these were found, upon measuring the portion of 
nerve, to have produced no contraction in its 
length. When this portion was separated, as in 
the former experiments, it contracted to 11| inches, 
a diminution of f of an inch. 

The electric fluid, in this last experiment, excited 
the action of the diaphragm, but produced no evi- 
dent or permanent contraction of the nerve ; and, 
when the nature of the contraction of a nerve is 
considered, it is not to be expected that permanent 
contraction can be ascertained in any other way, 
than by separating entirely a portion of nerve from 
the rest of the system. For the action is continu- 
ed in tremors along the nerve, in quick succession ; 
and, when the muscle has been excited to contract. 



*4£ ON THE IRRITABILITY 

the complete action of the nerve is finished, and it 
immediately relaxes, or returns to that state which 
admits of a new action. 

This appeared to be the case in several experi- 
ments made upon the nerves of frogs, and of quad- 
rupeds of a higher order, by two different metals, 
as described by Galvani. In all of them there was 
a convulsion of the muscle, and a tremor in the 
nerve ; but, such was the rapidity of the effect, that 
it could not be decided that any motion took place 
in the nerve, except what arose from the agitation 
produced by the action of the muscle. 

The experiments and observations which have 
been related appear to illustrate an action in the 
nervous chords, capable of producing the symptoms 
which occurred in the case related in the former 
part of this chapter, and also those met with in 
many other diseases, the symptoms of which have 
never been satisfactorily explained. 

The hypothesis of a nervous fluid, although it 
may explain every symptom which originates in 
the brain, and from thence pervades any part of 
the system, and every symptom which begins in 
the extreme parts and goes to the brain, does not 
give a satisfactory solution of those nervous agita- 
tions brought upon an extreme part 5 which only 



OF THE NERVOUS CHORDS. 149 

proceed for some way in the course of a nerve, 
and are there arrested, without being allowed to 
proceed to the brain. 

The circumstance of nerves having been divided, 
and their functions being restored twelve or twenty- 
four months after, when the two cut ends have been 
united by a new substance, is a strong argument 
against the circulation of a nervous fluid ; since no 
such effect takes place in the pervious canals of 
the body. 

In many diseases, there are symptoms so deci- 
dedly confined to the course of the nervous chords, 
that an impartial observer would be unable to ac- 
count for them in any other way, than by supposing 
them to arise from some action in the nerves 
themselves. 

This idea must have been strongly impressed 
upon the mind of Dr. Mead, who, in treating of 
his third sort of Quincy, says, all the nerves are 
convulsed, and the patient drops down dead sud- 
denly.* 

The Tic douleureux is a remarkable instance of 
this kind, both in the circumstances under which 

* Mead's Prsecepta Medica. Quarto, p. 434, 
N 2 



150 ON THE IRRITABILITY 

the spasmodic tremors are brought on, and the 
manner in which they are propagated along the 
nerve. 

In one case of this disease, in which the opera- 
tion of dividing the nerve was performed, with a 
view to remove the complaint, union by the first 
intention did not take place ; and, during the time 
the wound was open, the inflamed state of the cut 
end of the nerve made the patient liable to several 
attacks of the disease, similar to those he experi- 
enced before the operation ; but there was no re- 
currence of them after the wound was completely 
healed. 

This is a very important fact ; as it proves that 
inflammation on the cut end of a nerve, while in 
an irritable state, is capable of producing exactly 
the same symptoms as the original disease. This 
effect of inflammation upon the end of a nerve ex- 
plains the startings of the limb, which occur too 
frequently after amputation. 

These most commonly are met with when the 
limb is taken off above the knee, and the nerves 
and vessels have been previously inflamed higher 
than the part at which they were divided ; and 
where the nerve is confined by the thickened state 
of the surrounding parts. 



OF THE NERVOUS CHORDS. 151 

The same fact also explains the cause of locked 
jaw, when it is produced by a wound or bruise 
upon a nerve, in a constitution either rendered irri- 
table by climate, or naturally so ; also, where the 
nerve itself becomes diseased, in consequence of 
the accident. 

The following case of locked jaw, from an in- 
jury to the thumb, bears so great a resemblance to 
the case related in the beginning of this paper, as 
to show that the diseases must be nearly allied. 

A lady of a very irritable habit was overturned 
in her carriage, and hurt her thumb, which swell- 
ed very much ; and the skin over the metacarpal 
bone of the fore-finger, about the size of a shilling, 
sloughed off. No symptoms came on for fourteen 
days after the accident, when, upon bending her 
fingers, violent spasms took place in the thumb, 
which proceeded up to the neck and lower jaw ; 
these were exceedingly painful, and the jaw was 
so much shut, as hardly to admit a tea-spoon. In 
fourteen days more, the jaw began to open ; and, 
for a month longer, there were only two or three 
spasms daily in the thumb, attended with pain ; 
these went up the arm to the jaw. At the end of 
that period the sore on the back of the hand heal- 
ed, and she recovered perfectly from the spasmodic 
affections, 



152 ON THE IRRITABILITY 

This action of the nerves likewise enables us to 
understand the spasmodic affections which some- 
times occur in the limbs upon which there are irri- 
table ulcers. These spasms arise from the exposed 
extremities of the nerves being irritated to an unu- 
sual degree; and this irritation not being confined 
to the surface of the ulcer, but communicated 
along the course of the nerves, excites an action in 
those chords, as high as the irritation is conveyed ; 
and a consequent contraction in the muscles to 
which these nerves belong. These spasmodic af- 
fections are, therefore, not wholly dependant on 
the state of the constitution, as has been in general 
believed, but are decidedly the symptoms of a local 
complaint, and within the reach of local treatment, 
both for their palliation and removal. 

It is highly probable, that in many cases of ulcer, 
the extremities of the nerves that are newly formed 
in the granulations are more under the influence of 
external impressions than naturally formed parts, 
and communicate their action to the nervous chords, 
of which they are a continuation, producing spas- 
modic affections of different kinds, which would be 
immediately removed, were those sentient extre- 
mities destroyed. 

The following case is in favour of such an opi- 
nion j the history is drawn up by Mr. Hen- 



OF *THE NERVOUS CHORDS. 153 

mng, the surgeon who had the patient under his 



care. 



A gentleman, who is now 50 years old, when at 
the age of 36, had a paralytic affection of the right 
leg and arm, and has never acquired more than a 
very imperfect use of them. Ten years subse- 
quent to this attack, the scratch of a cat, on his 
outer ancle, formed an ulcer, which healed with 
difficulty. From that time to the present, ulcers 
have often occurred on his legs, and though they 
were always sluggish, yet no uncommon effects at- 
tended them. Eighteen months ago, the cicatrix 
of an ulcer, just beneath the outer ancle of the 
right leg, and two others, in nearly the same situa- 
tion on the left leg, broke out into sores. These 
ulcers, during six months, gave no particular unea- 
siness, but, about the end of that time, the usual 
dressings began to give pain, and this was attended 
with involuntary motions of the lower limbs. Dur- 
ing the following six months every application was 
used, which suggested itself to the different sur- 
geons who were consulted. The ulcers, however, 
remained stationary, and the contractions became 
still more severe. Opium, which at first controuled 
the spasms, soon lost its influence. 

On the 1st of January, 1801, he became Mr* 
Henning's patient. There was then a manifest 



154 ON THE IRRITABILITY 

difference of character in the ulcers on the paralytic 
limb, from those on the other limb. The edges 
of the skin, which surrounded the former, being 
thick, prominent, smooth, and rounded ; while 
those of the others were jagged, and terminating 
in an edge, sharp, and undermined. In other re- 
spects they were alike, having their surfaces cover- 
ed with flakes of coagulated lymph, which could 
not be wiped off; and a discharge of ill-formed 
pus. Both legs were sedematous as high as the 
calf. The most cautious touch of a probe covered 
with lint gave exquisite pain, which was instantly 
followed by quiverings of the skin, in the course 
of the superficial branch of the peroneal nerve. 
These were followed by spasms of the muscles, 
the heels were drawn inwards and backwards, the 
knees drawn up towards the chin ; sometimes the 
patient was jerked out of his chair by their sudden 
violence ; in general, however, these motions, 
though irresistibly strong, were gradual, and gave 
him time to counteract them, by changing the posi- 
tion of his body, and grasping the chair with his 
hands. By firmly pressing on the nerve, Mr. Hen* 
ning was sometimes able to prevent the spasms, 
and sometimes to subdue them ; but the pressure 
that was requisite could not long be endured, so 
that when spasms occurred, no means were employ* 
ed to resist them, and they went off gradually. 



OF THE NERVOUS CHORDS. 155 

The ordinary number of his pulse was 78, but 
when the spasms were severe, it frequently was 
found to be 110. 

It seemed obvious that the spasms had originally 
been produced by the irritable state of the ulcers, 
yet the risque of increasing their violence pre- 
cluded the use of active dressings, at least till it 
should be ascertained, whether the sensibility of 
the nerves might not be blunted by sedatives. 
With this view, an ointment, composed of pitch 
and sallad oil, was applied to the ulcers, • and it 
afforded a perfect remission of the spasms during 
three days. Then its power was greatly diminish- 
ed, and soon after the spasms recurred on the 
slightest irritation. The balsam of Peru, extolled 
by Dr. Kirkland in this kind of ulcer, when used, 
threw the muscles into the most violent contrac- 
tions, and every sedative that was employed pro- 
duced the same effect. It was therefore judged 
expedient to change the plan, but irritating dress- 
ings were insufferable. 

Dr. Underwood was consulted, who proposed 
quieting the parts, by sedative applications, but 
they all failed. Mr. Home was afterwards called 
in, and recommended a trial of Mr. Baynton's 
plan of the adhesive plaster ; under this treatment 
the ulcer on the paralytic leg filled up with healthv 



156 GN THE IRRITABILITY 

granulations, which at once put an end to the 
spasms. But the plasters, though applied with 
the nicest care, could not be borne by the other 
leg. 

Soon after this, a severe erysipelas overspread 
the whole leg and foot, and two abscesses formed; 
these broke ; and the sores thus produced were 
healed by stimulating dressings and pressure : no 
spasms were brought on by the pain of these 
dressings. It was expected that some improve- 
ment would have been derived to the old ulcers 
from this attack, but they were not in the slightest 
degree affected by it. 

Mr. Henning, after so many fruitless attempts, 
was led to destroy the irritated surface of the 
ulcers, by touching them with a strong solution of 
nitrated silver, and to diminish the pain arising 
from its action by means of a full dose of opium ; 
the effects of this application proved milder than 
those of any which had been employed, except the 
pitch. It was therefore repeated daily ; after the 
second application, a healthy granulated surface 
took the place of that which has been described, 
and the discharge was converted into perfect pus. 
The spasms diminished in frequency and strength* 
and soon ceased entirely. 



OF THE NERVOUS SYSTEM. 15 7 

On the 25th of June the patient began to feel ner- 
vous twitches in his right cheek ; they were brought 
on by cold, by friction, or even the touch of a finger. 
This affection is confined to the second branch of 
the fifth pair of nerves, and is evidently the tic 
douleureux. These appeared to be gradually in- 
creasing upon him on the Tth of July, the time this 
case was drawn up. 

A soldier had a superficial ulcer, four inches 
square, upon the skin of the shoulder, not going- 
deeper than the cutis ; this began to heal very kind- 
ly, and in the course of five days so great a part of 
it had skinned over, that there was only an ulcer 
of half an inch square, with a tolerably healthy ap- 
pearance. At this time symptoms of lock-jaw came 
on, and in three days he died, although there was 
no other complaint whatever to bring on the lock- 
jaw than this small ulcer. If, upon the first appear- 
ance of the symptoms of lock-jaw, the surface of the 
ulcer had been destroyed by caustic, it is probable, 
from the preceding case, that the disease might have 
been stopped in its course, or entirely removed. 



CHAPTER VII. 

OP ULCERS IN PARTS WHOSE ACTIONS ARE TOO 
INDOLENT TO FORM HEALTHY GRANULATIONS, 
WHETHER THIS INDOLENCE ARISES FROM THE 
STATE OF THE PARTS, OR OF THE CONSTITU- 
TION. 

X HE appearance of ulcers attended with indo- 
lence, is the very reverse of that which was des- 
cribed in those of the irritable kind. The edges 
of the surrounding skin are thick, prominent, 
smooth, and rounded. The granulations are smooth 
and glossy on the surface. The pus is imper- 
fectly formed, but not thin and watery ; it con- 
sists of pus and coagulating lymph mixed. The 
lymph is made up of flakes, and is with difficulty 
separated from the surface of the granulations ; so 
that when the ulcer is wiped clean, the coagulating 
lymph adheres in several places, giving a white ap- 
pearance to these parts of the ulcer. The bottom 
of the ulcer is commonly all of the same level, or 
nearly so. The general aspect gives the idea of a 
portion of the skin and parts underneath having been 



OT ULCERS ATTENDED, &C. 159 

for some time removed, and the exposed surface not 
having commenced any new action to fill up the 
cavity. 

These appearances are only met with in the truly 
indolent ulcers, in which the symptoms are the most 
strongly marked : in others of this species the ap- 
pearances very much resemble those that belong to 
the last mentioned species, when of the milder kind, 
and are only to be distinguished from them by the 
circumstance of mild and soothing applications being 
either of no service, or even aggravating the symp- 
toms, which is frequently the case* 

It may on the first view appear strange that the 
irritable and indolent ulcers, which are so very op- 
posite in their nature, should ever have the slight- 
est resemblance ; but when it is considered that 
ulcers change their appearances very readily, accord- 
ing to variations in the state of the constitution, or any 
accidental circumstance which may have affected the 
parts, it will be readily comprehended. An indo- 
lent ulcer, after any violent exertion of the limb, 
will have more or less of an irritable appearance. 
If the patient is exposed to cold, and kept without 
wholesome food, similar changes will be produced. 
Under any temporary constitutional indisposition 



160 



OF ULCERS ATTENDED 



ihe ulcer will spread, and be for a time in an irrita- 
ble state. 

It is this species of ulcer which deprives the army 
of the service of so many men, and which has, with 
too much truth, been considered as the opprobrium 
of surgery. In the army, when ulcers from com- 
mon accidents are not attended to, the patients con- 
tinue to do their duty in the regiment, use violent 
exercise, and are guilty of every kind of irregularity : 
under these circumstances, the ulcers soon degene- 
rate into the indolent kind, and when arrived at 
this state they are considered as incurable. 

Many of these ulcers heal in a very short time after 
the men are discharged, their own desire to get well 
making them give every assistance to the surgeon's 
txertions for that purpose, and the patients are af- 
terwards met with in newly raised corps, in which 
they had re-enlisted. This is a fact within every 
military man's knowledge, and is a sufficient proof 
that the ulcers for which soldiers are invalided are 
by no means all of them incurable ; nor are the men 
rendered unfit to do the duties of soldiers. If some 
of them are cured after having arrived at the worst 
state, and after having remained (which they must 
have done) for some time in that condition, what 



WITH INDOLENCE. 161 

might not have been effected, had they been earlier 
put upon the right mode of treatment ? 

To this species also belong the greater numbex 
of those ulcers that are received into the London hos- 
pitals, more especially in men, many of which are 
cured there, although they have perhaps continued 
for several years. 

Length of continuance alone appears sufficient to 
give an indolent disposition to an ulcer. It is there- 
fore immaterial, whether in its origin it was healthy, 
only attended with weakness, or even irritable ; if 
not cured within a certain time, it becomes indolent. 
This is not, however, always true with regard to the 
irritable kind, many of which remain so, whatever 
length of time the complaint may have continued. 

An indolent ulcer may be imagined, from its name, 
and the general length of its continuance, to remain 
nearly stationary, making little or no progress to- 
wards a cure ; but this is not the case, so great a 
degree of indolence being rarely met with. Such 
an ulcer is generally forming granulations, but they 
are unable to support themselves beyond a very 
short period ; it appears, therefore, to proceed to- 
wards amendment, although very slowly, so long as 
the granulations stand their ground - 9 and then, all at 
02 



262 OF ULCERS ATTENDED 

once, when they are absorbed, the ulcer spreads 
nearly to its original size, twenty-four hours undo- 
ing all that had been formed in so many days, or 
even weeks. This is a change which takes place so 
constantly, and under such different circumstances, 
that it cannot be attributed to any external cause, 
but must be supposed to arise from the granulations 
which are formed in that indolent state of parts be- 
ing unfit to answer the purpose for which they were 
intended, and therefore giving way. It is, howe- 
ver, brought on and increased by occasional causes ; 
as changes in the weather, anxiety of mind, or too 
great fatigue. 

It is a curious fact, that there should be the same 
want of powers in the granulations formed in indo- 
lent ulcers, as in those attended with weakness : al- 
though the circumstances seem to be so very differ- 
ent : in both, the granulations are unhealthy ; in the 
one, indeed, they are luxuriant, while in the other 
they are deficient. Every deviation from the heal- 
thy action, whether it be too great action in weak- 
ened parts, or too little action in indolent parts, 
equally renders them incapable of forming granu- 
lations, strong enough to support themselves under 
the necessary actions of the parts to which they be- 
long. Those formed in the indolent ulcer are much 
weaker in their living powers than the others ; for 



WITH INDOLENCE. 16o 

they are absorbed without any evident cause, their 
powers of life being exhausted, and no longer able 
to support them. 

That in the present species of ulcer, this unheal- 
thiness in the granulations is the effect of indolence 
is rendered highly probable ; since in some instan- 
ces it exists in a greater degree when the patient is 
perfectly quiet, and lies in an horizontal position, 
than when he is more actively employed ; the com- 
mon motions of the limb rousing up the actions of 
the parts, and making them approach more nearly 
to those of health. A bandage moderately tight, 
as it gives a support to the muscles, and, by com- 
pressing the superficial veins, renders the circula- 
tion of the blood in them less languid, seems also 
materially to assist the cure ; it admits of the limb 
being used, without so readily feeling uneasiness 
from fatigue. 

Many cases have been cured by means of a tight 
bandage and exercise, after other methods of a mild- 
er kind had failed. So successful has this practice 
been, that we find it recommended in all cases of old 
ulcers. 

This probably carries the system too far ; there 
is, however, sufficient evidence to prove, that rest 



164 OF ULCERS ATTENDED 

is less necessary in cases of indolent ulcers, than in 
many others. The good effects of this plan may 
partly arise from counteracting those of confinement 
and a sedentary life, which are, to some constitu- 
tions, so extremely hurtful, as to prevent an ulcer, 
from healing while the patient continues under these 
circumstances. This is very often found to be the 
case in hospitals, particularly with patients who 
have lived much in the country, and whose employ- 
ment has been in the fields ; as gardeners, and hus- 
bandmen. Soldiers are taken from various modes 
of life, but many of them must be of this descrip- 
tion. 

In indolent ulcers it must appear, from what has 
been said, that there is a backwardness in forming 
granulations ; and, in those granulations that are 
formed, a want of sufficient health or strength to 
form a complete cure. The first of these effects of 
indolence is the only one which has been generally 
attended to in practice ; the surgeon being satisfied 
if he could in any way heal up the ulcer. This is 
a very imperfect mode, since we find, that when 
they are healed by only increasing the growth of the 
granulations, without altering their disposition, the 
parts will very soon give way again. 



WITH INDOLENCE. 165 

The object of our treatment should be, not simply 
to produce a cure, but to render that cure as perma- 
nent as possible. This is only to be done by chang- 
ing the disposition of the granulations, and render- 
ing them strong enough to stand their ground, after 
the ulcer is completely filled up. It is in this view 
the modes of treatment will be considered. 

That the granulations which are formed in ulcers 
of this species differ very much, in respect to their 
health and strength, according to the applications 
which are used during their growth, is sufficiently 
evinced from daily experience. It may, however, 
be very readily demonstrated by the following easy 
experiment. Let an ulcer of six months standing, 
which has acquired an indolent disposition, have a 
poultice of bread and milk applied to it for a week ; 
and at the end of that period examine the granula- 
tions ; they will commonly have in part filled up the 
ulcer, but they will also commonly be large, loose, 
and glossy in their appearance. If the poultice is 
now left off, and some stimulating medicine, which 
agrees with the ulcer, is used for another week, the 
granulations, when again examined, will in general 
be found to have undergone a considerable change, 
appearing smaller, more compact, redder, and with- 
out gloss. Where this is the case, it is natural to 
suppose that the ulcer healed under the last men- 



166 OF ULCERS ATTENDED 

tioned application will be less liable to break out 
than under the former ; the materials by which it 
is filled up being of a more healthy kind. The truth 
of this opinion is not confined to reasoning, but is 
confirmed by experience. My own observations 
upon this subject may possibly be thought less im- 
partial than those made by any other person ; this 
leads me to prefer giving the results which a gen- 
tleman, who had extensive opportunities of seeing, 
ulcers treated in these different ways, was led to 
draw from the facts that came within his notice. 
He stated, at a medium, that the number of ulcers 
healed under the use of stimulating medicines, which 
did not break out again in a short time after getting 
well, compared with similar cases under a milder 
treatment, were as four to one ; his remarks were 
communicated to me, some time after they were 
made, by a gentleman who consulted me as a patient. 
After having stated these observations made by ano- 
ther surgeon, it is proper to add, that my experience 
leads to similar conclusions. 

Having so decidedly given a preference to the 
use of stimulating medicines, in those varieties of 
indolent ulcers which admit of being healed by dif- 
ferent modes of treatment, it will be unnecessary to 
add, that there is a very small proportion of them 
that come under that description ; the greater num- 



WITH INDOLENCE, 167 

ber not being sufficiently within the influence of 
mild dressings to admit even of a temporary cure. 

The medicines which have been found best 
adapted to promote the cure of indolent ulcers, 
under the different circumstances in which they 
occur in practice, will now be enumerated. 

Or APPLICATIONS, CONSIDERED WITH REFERENCE 
TO THIS SPECIES OF ULCER. 

1. In the form of vapour. 

Medicines in this form are very commonly em- 
ployed in cases of indolent ulcers ; but from the 
observations which have now been made, it must 
appear that they are not such as can promote the 
cure with advantage, nor should they ever be ap- 
plied with that view. Recourse is only to be had 
to them, when the ulcer, in consequence of some 
accidental cause, has put on a foul appearance, and 
may be said to be in a state of temporary irritation. 
As this is unconnected with the original disposition 
of the ulcer, and it is more properly during that 
period an irritable ulcer than an indolent one, it is 
to be treated as such till the parts return to their 
indolent state. 



168 OF ULCERS ATTENDED 

It has been found that soldiers who have had 
ulcers of some standing, that were in an indolent 
state, could bear the usual daily exercise, while in 
fixed situations, without being made worse by it ; 
but if the men at any time had been obliged to 
march for several, days together, or had been 
employed on any duty of fatigue, the ulcers put on 
so very irritable an appearance, as to give the idea 
of being irritable ulcers of the worst kind. It is 
therefore necessary, in forming an opinion upon 
such cases, to inquire into the conduct of the men 
for some days previous to the examination. 

The patients who are received into our London 
hospitals, from having used too much exercise, and 
from excesses of different kinds, have in general 
their ulcers in this irritated state, requiring the use 
of fomentations and poultices for some time, before 
the treatment necessary for the cure of the ulcer 
can be adopted. 

The fomentations in use are the decoctions of dif- 
ferent herbs, which are supposed, from their pro- 
perties, to cleanse the ulcer, and give it a better ap- 
pearance ; and it is highly probable that they de- 
serve this character ; but the warmth which is 
conveyed to the ulcer is, I believe, the most material 
circumstance in the application. The decoctions of 



WITH INDOLENCE. 169 

chamomile, southernwood, wormwood, and of laurel 
leaves, are considered as best adapted to this state 
of such ulcers. When the ulcer is spreading, and 
very painful, decoction of poppies alone, or mixed 
with equal proportion of proof spirit, is often of 
service. The fomentations are commonly applied 
by means of flannels, for about ten minutes or a 
quarter of an hour each time the poultice is changed, 
which is generally twice in the twenty-four hours* 

2. In a watery form, or in a moist state. 

Poultices are used with the same view as the 
fomentations, and they may be considered as dif- 
ferent parts of the same mode of treatment. The 
fomentations are the occasional, the poultice the 
continued, application. Poultices for this purpose 
are made of the same liquors as are used for 
fomentations ; but, for the substance of the poultice, 
bread, oatmeal, or linseed meal, may be used. 

As both the fomentations and poultices are only 
intended to bring the ulcer into a proper state to 
admit of being cured, they are rather preparatory 
steps than any part of the regular treatment of such 
ulcers. In their common state there is no occasion 
to have recourse to these applications, 
p 



170 OF ULCERS ATTENDED 

In the treatment of indolent ulcers it is very natu- 
ral to suppose that all medicines, whether stimula- 
ting or otherwise, will have a material advantage 
when used in a watery form, since they w T ill mix 
with the matter, be more intimately applied to the 
surface of the ulcer, and remain in contact with it 
for a longer time ; this is, however, only true with 
respect to the milder applications ; for to those that 
are very stimulating, no such continuance of contact 
is necessary, and were it accomplished, would 
probably prove hurtful, since the stimulating effects 
might exceed what the parts can bear. 

As ulcers of this species require stimulating me- 
dicines, there is therefore no reason for preferring 
watery to unctuous applications, further than as 
they may happen to agree better with particular 

cases. 

When stimulating applications are used to indo- 
lent ulcers, it is always to be understood that the 
medicine is only intended to stimulate the parts to 
action ; but the actions are to be performed by the 
parts themselves, which, when once stimulated, will 
proceed to act in consequence of that stimulus, 
for a considerable time after the immediate effect 
of the local application has ceased. The stimula- 
ting medicine is therefore only to be repeated as 



WITH INDOLENCE. 171 

often as is found necessary, to prevent the parts 
from falling back into their indolent state. 

It is in this way only that the effects of stimula- 
ting medicines can be explained ; such as a single 
drop of tincture of opium dropped, once in twenty- 
four hours, upon the cornea and tunica conjunctiva 
of the eye, removing an inflammation of the eye, 
although the tincture is scarcely allowed to remain 
more than a second of time in contact with the 
parts ; as the tears immediately wash it off. 

The application of sea water to a swelled hand 
for ten minutes, once in twenty-four hours, will 
frequently excite the actions of the absorbents, 
which will then probably continue to act, so that 
the swelling in a few days will be completely re- 
moved. 

In these instances the exact time the medicine is 
applied can be determined with precision, and is 
very short ; and were it longer, it would, by being 
too violent, do harm. In other instances stimula- 
ting medicines act upon the same principle, and are 
in general not much longer in immediate contact 
with the surface of the ulcer. 



172 OF ULCERS ATTENDED 

There are indolent ulcers which occur in patients 
of debilitated constitutions, that put on a sphace- 
lated appearance, (even after they have made some 
progress towards a cure) without any apparent 
cause, and in this way spread to a very large size. 
This unpleasant change must be the consequence of 
weakness in the newly formed parts, and some in- 
disposition of the general system/ The varieties of 
this kind that will be necessarily met with in dif- 
ferent patients must be very great ; and among 
them there will be some, which, were they classed 
according to their appearances, would be generally 
allowed to belong to the species of irritable ulcers : 
but as they do not recover under soothing applica- 
tions, they cannot, according to the principles that 
have been laid down, be separated from the species 
of indolent ulcers, of which they appear to be an 
uncommon variety. They occur in seamen, and 
land troops which have been long at sea, and when 
met with in that class of men have been called scor- 
butic ulcers. They are not, however, in any way, 
necessarily connected with the sea scurvy, being 
but too frequently met w T ith on shore, in patients 
who have never been affected by that disease. 

They are frequently met with in the West Indies, 
in soldiers who had lost their health from the ef- 
fects of climate ; they are not uncommonly met 



WITH INDOLENCE. 173 

with in the London hospitals, in men whose general 
health has been impaired by the free use of spiri- 
tuous liquors : and therefore ought to be considered 
as not belonging to any specific disease, but as com- 
mon to men whose constitutions are greatly debili- 
tated, whether by salt provisions, the effect of warm 
climates, or the use of ardent spirits. 

In such ulcers a new mode of treatment has been 
very strongly recommended by Dr. Harness, 
Physician to the Navy, and one of the Com- 
missioners of sick and hurt seamen, who found that 
the gastric juice of ruminating animals, used as an 
external application, made the ulcer, when in a 
sphacelated state, throw off the sloughs, and put on 
a milder appearance ; and by a continuance of the 
same medicine the cure was completed. This he 
afterwards tried in many instances, and was in gene- 
ral sucessful. 

I was naturally led, from so favourable an account, 
to make use of the gastric juice in ulcers of this 
description. It gave a good deal of pain on each 
application, which lasted for nearly half an hour ; 
but the ulcer in two days put on a better appearance, 
and all the sloughs were thrown off. From the pain 
it occasioned, it must be considered as a stimulating 
application. 

P2 



174 OF ULCERS ATTENDED 

In one case of a patient in St. George's hospital, 
the gastric juice brought an ulcer of this kind into a 
favourable state, after which it appeared to be 
stationary ; but whenever the gastric juice was chang- 
ed for any other dressing, the ulcer spread ; and 
when it was again used resumed its favourable ap- 
pearance : this happened three different times ; the 
gastric juice must therefore, in this particular in- 
stance, appear to have been the only dressing that 
agreed with it. 

The gastric juice, as procured from bullocks or 
sheep, must certainly be in a very diluted state ; as 
the liquor found in the true or last stomach, which 
is the only one that contains it, is in the quantity of 
two or three pints in the ox, and two or three ounces 
in the sheep. This practice appears particularly 
adapted to these ulcers when they occur in seamen ; 
and Dr. Harness considers it as equally successful 
in the truly scorbutic ulcer. Of this, however, in 
London there is no opportunity of making trials. If 
this be really the case, it is fortunate that seamen 
are usually placed for cure in situations where the 
gastric juice can be very easily procured; as the 
animals killed for victualling the navy, in the 
vicinity of the naval hospitals, afford an ample sup- 
ply for daily use. 



WITH INDOLENCE. 17 o 

In the West Indies, where too many cases occur 
among the soldiers, bearing a resemblance to those 
relieved by the application of the gastric juice, the 
fresh root of the cassada grated into a pulp is em- 
ployed with evident advantage.^ This juice is a 
poison, taken into the stomach, it must therefore be 
considered as a stimulating application. In this 
state of ulcer, lime juice has also been used with 
great advantage. Solutions of vitriol and alum 
have been recommended ; but I cannot speak, from 
my own experience, at all in their favour. 

When an indolent ulcer has none of the peculiari- 
ties which have been mentioned, the stimulating ap- 
plications in a watery form, that appear the best 
adapted for promoting a cure, are the following. 

The solution of argentum nitratum, or lunar 
caustic, is a very useful medicine as a local ap- 
plication, and one of the best in general use. It 
stimulates the granulations, and makes them put on 
a more healthy appearance. It agrees with indolent 
ulcers in a greater number of patients than many 
other medicines. It has a material advantage, in 
being capable of having its strength increased to any 
.degree that can be required, so as always to adapt 

* The cassada is the Satropha Manihotof Linnaeus . 



176 OJ? ULCERS ATTENDED 

it to the actual state of the ulcer. This is the more 
necessary, since indolent ulcers, when they have 
been accustomed to any application, which they are, 
in general, very soon, they no longer receive much 
benefit from its use. 

It is a curious circumstance, that an ulcer which 
at first is unable to bear this solution of more than 
a certain strength, without pain, and without the 
granulations themselves being absorbed, will usually, 
from the continuance of the same application for ten 
days or a fortnight only, be able to bear it of a 
double strength, without either of these effects being 
produced ; and that this increased strength will now 
be necessary to give the same degree of stimulus, 
which had before been produced by the weaker 
solution. This may be considered as a proof that 
the granulations are become much stronger than 
they wti e before . 

Tincture of myrrh, either pure or diluted, which- 
ever is found best adapted to the state of the ulcer, 
is, in many instances a good application ; it rouses 
up the actions of the parts, and gives the granula- 
tions a better appearance. But where the ulcer is 
Very indolent, it soon loses its effects, as has been 
already mentioned to be the case with many other 
medicines. 



WITH INDOLENCE. 177 

rhe good effects of the tincture of myrrh have 
been sufficiently established, by general practice, to 
give it a place among the medicines in use for indo- 
lent ulcers on the legs j but as the opinions of 
practitioners may differ respecting the extent of its 
powers, it is right to mention the following proof, 
taken from a wound of a different kind, as it ap- 
pears to be a strong evidence in its favour. 

A gentleman was cut for the stone, and the 
wound, some time after the operation, became 
sloughy ; it was so indolent as not to throw off the 
sloughs, and from the urine passing over it, the edge 
of the divided skin was covered with a crust of 
calculous matte r, so that there was not the smallest 
disposition to heal. Several medicines were ex- 
ternally applied, to alter the state of the wound, 
without effect ; but tincture of myrrh not only an- 
swered that purpose, but under its use the parts 
were entirely healed. 

The tincture of myrrh having considerable 
powers as an external application, led to the idea of 
giving it, in a variety of instances, internally, at the 
same time that it was externally applied, with a 
view to ascertain its local effects through the medium 
of the constitution ; but no evident benefit was 
produced by using it in this way. 



i78 OF ULCERS ATTENDED 

Decoction of the walnut-tree leaves, and of the soft 
covering of the walnut, have been strongly recom- 
mended by a surgeon of eminence in Vienna, who 
states, that its powers in disposing foul ulcers to 
heal are beyond those of many other medicines. 1 * I 
have used it in a number of cases of indolent ulcers, 
and can, from experience, give evidence in its 
favour. 

The diluted vitriolic acid has been employed in 
particular cases, and has been recommended as a 
medicine proper for such ulcers ; it has not, how- 
ever, been sufficiently successful to bring it into 
general use. From my own knowledge I am un- 
able to speak of it, never having seen it used, but 
have lately heard it well spoken of by an army sur- 
geon, for whose opinion I have a high respect. 

The expressed juice of the pod of different spe- 
cies of pepper, in a recent state, has been used as an 
ingredient in the applications to ulcers of an indolent 
kind, both in the East and West Indies. What the 
real powers of the peppers are, when externally ap- 

* Dissertatio de utilitate decocti corticum nucum juglandium 
siccatorum in tractandis ulceribus, Authore Dr Joanni Hune- 
zowsky. Acta Academ. Medic. Chirurg". Yindoboniensis. Tom. 
prim. 1788. 



WITH INDOLENCE. 179 

plied in this way, I have had no opportunities of as- 
certaining, nor can it be procured in this country for 
trials to be made with it. 

The peppers, given internally, have a power of 
disposing indolent ulcers to heal, by exciting a de- 
gree of action in the parts beyond what is natural 
to them. It is in this way that Ward's paste dis- 
poses slight cases of fistulae in ano to heal ; and 
makes the wound, after the operation for a fistula, 
put on a more healthy appearance. The peppers 
have been known to make a fistula in perinseo close 
up. This practice may very reasonably be extended 
to indolent ulcers on the legs ; but I have not yet 
had any experience of its internal use in such cases, 
and therefore mention it only as deserving of trial. 

After having mentioned the medicines in com- 
mon use to indolent ulcers, it is proposed to add 
one which has not been before laid before the pub- 
lic. 

The nitrous acid, diluted to such a degree as 
will fit it for an external application, is found, by 
experience, to be a very useful medicine. The 
proportions must be varied according to circum- 
stances ; but a scruple to eight ounces of water will 
in general answer. The best mode of ascertain- 



180 OF ULCERS ATTENDED. 

ing the proper degree of strength for this solution 
is by applying it to the tongue, and when it stimu- 
lates without being acrid, it is of a proper strength 
to begin with. 

In bringing forward any new medicine, it is not 
sufficient to mention its effects ; it is also proper 
to state the reasons that led to its adoption, so that 
the grounds upon which it was taken up may be 
fairly understood. 

In considering the different application to indo- 
lent ulcers which are in common use, I was led to 
remark that three of them, on which experience 
had led me to place the greatest dependance, had 
the nitrous acid as one of their component parts ; 
the other part being either mercury or silver. This 
is the case with the unguentum hydrargyri nitrati, 
the argentum nitratum, and the hydrargyrum nitra- 
tum rubrum. This circumstance appeared deserv- 
ing of attention, and induced me to believe, that as 
these three chemical preparations are applied in a 
very diluted form, they must be in part decompo- 
sed ; and in the argentum nitratum some of the 
metal is separated in form of a powder, before the 
application is actually made to the ulcer. If this 
is the case, the detatched acid will mix with the 



WITH INDOLENCE, 181 

water, so that the efficient part of this medicine, lo 
cally employed, must be the nitrous acid. 

Upon these grounds the effects of that acid wen 
tried on ulcers of different kinds. With those that 
were irritable it evidently disagreed. In those that 
were attended with weakness, in some instances* 
and in a very diluted state, it produced an amend- 
ment ; in others, it retarded their progress ; but in 
many of the indolent ulcers it promoted, in a very 
uncommon manner, the progress of the cure. 

The apparent effect of the nitrous acid as an ex- 
ternal application, is different from that of most 
other medicines of a stimulating nature : it dimin- 
ishes the quantity of matter or pus, and instead of 
giving a healthy, florid appearance to the surface of 
the ulcer, there is a soft ash-coloured coagulum, 
which partially covers the granulations : near the 
circumference this is more compact and harder ; it 
there forms a complete crust, and firmly adheres to 
the surface. If the bottom of the ulcer is nearly 
on the same plane, the greater part of it has this 
coagulum spread over it, with small interstices, 
through which the granulations are seen. If the 
ulcer is hollow in the middle, and gradually rises 
at the edges, the crust is met with on the circum- 
ference or outer edges, while the softer coagulum 



182 OF ULCERS ATTENDED 

is seen within these edges, and in the centre is com- 
mon pus, till it has attained the level of the other 
parts. There is a succession of these crusts form- 
ed upon the margin of the ulcer, one under the 
other : these crusts bear a greater resemblance to 
• aminae of common cuticle than any thing else, and 
the parts underneath evidently rise higher and high- 
er, till they come nearly to the level of the common 
skin. When that is the case, the crusts are longer 
in separating by four or five days, and on their re- 
moval a very perfect cuticle appears underneath ; 
much more so than is usually met with in an ulcer 
cicatrized by means of other dressings 

The diluted nitrous acid gives a good deal of 
pain on its first application, this lasts for about half 
an hour, and then goes off ; the pain is afterwards 
less severe. 

In one case of a very indolent ulcer the nitrous 
acid was applied, in the proportion of two drams 
to ten ounces of water ; it gave little pain, and the 
parts began to put on a more healthy appearance ; 
but after having done so, their sensibility was so 
much increased, that a solution one third of the 
former strength gave pain, and was rather stronger 
than the parts could now bear. 



WITH INDOLENCE. 183 

The progress in the healing of an ulcer to which 
the diluted nitrous acid is applied, differs so much 
from what we commonly meet with, the process of 
skinning is so much more rapid, and the new skin 
so much more completely formed, that it was natural 
to suppose that the medicine produces some very 
considerable change in the granulations, by which 
these effects are brought about. What this change 
is, has not been ascertained ; the only visible effect 
is the coagulation of the pus as it is secreted, which 
coagulum forms an external application to the 
granulations, and puts them in circumstances which 
appear more favourable for filling up parts, and 
forming new skin. This coagulated matter is thrown 
off by the pus next secreted, which is also coagulated 
in the same way, forming another lamina im- 
mediately in contact with the granulations. The 
manner in which the granulations increase, is hid- 
den by this covering, but from their rising higher 
and higher, it is evident that the parts are very 
active in forming them. 

Pus coagulated by the diluted nitrous acid forms 
a nidus for the granulations, which appears from the 
instances in which it has been tried, a better ap- 
plication to them than the pus itself, or many other 
medicines of a different kind. In a few weeks an 
ulcer of many years standing has skinned over, to 



*S4 Or ULCERS ATTENDED 

the extent of several square inches ; and the new 
skin, a few days after being formed, has very nearly 
resembled :aat of the surrounding parts. The skin, 
in various instances, has formed before the ulcer 
had been fille 3 up completely, so that the margin of 
the new skin was a good deal lower than the sur- 
rounding old skrn ; but some weeks after being skin- 
ned over, this ci iference of level gradually disap- 
peared. 

If the solution is too strong, it forms a hard 
:rust over the whole surface of the ulcer, giving it 
the appearance of being covered by a piece of dry 
parchment. This should be avoided, as the dried 
crust remains for several days, after which it is 
separated, and the progress of the cure is impeded 
while that process is taking plac"e ; so that bj such 
treatment an ulcer might be kept nearly stationary 
for months. If this medicine is injudiciously ap- 
plied, it will be found to produce that effect. 

A certain degree of indolence in the ulcer seems 
necessary, to admit this process to go on ; for in 
some cases the nitrous acid irritates, and makes 
the ulcer spread : and even in ulcers with which 
it agrees, and which heal very fast under its use, if a 
state of irritation is brought on, it becomes neces- 



WITH INDOLENCE. 185 

sary to leave it off, as the ulcer will then spread by 
a continuance of the application. 

In stating that the only visible effect of the ni 
trous acid is that of coagulating the pus, it is by no 
means intended to infer that no other effect is 
actually produced. On the contrary, there is reason 
to believe that it acts upon the granulations as a 
stimulating medicine, too violent for several species 
of ulcers, but adapted peculiarly to such as are 
indolent ; and that the coagulation of the pus is a 
chemical effect, which answers a secondary but a 
very salutary purpose. 

Several patients with ulcers, which had the nitrous 
acid applied to them, have been allowed to walk 
about and use exercise while under that treatment, 
and have not found the progress of the cure 
retarded, although no bandage that could in any 
way support the limb, was applied to it. This^ 
which there is reason to belive will be found to be 
generally true, is a circumstance very strongly in 
favour of this application. 

In cases of ulcers on the leg, in which there is a 

portion of bone exposed, which is neither acted 

upon by the absorbents, nor deprived of life so as to 

form an exfoliation, the ulcer is prevented from 
c^2 



186 OF ULCERS ATTENDED 

healing, under these circumstances, applying the 
solution of nitrous acid to the bone, removes the 
earthy part ; and excites the absorbents to act upon 
the animal portion which remains. 

By this treatment many ulcers have healed much 
sooner than they would otherwise have done. 

The effect of nitrous vapour, in destroying the of- 
fensive smell generated in confined apartments, con- 
taining a number of sick people, and its power of 
preventing contagion from spreading, are very val- 
uable discoveries, made by my friend Dr. Carmichael 
Smyth ; and there is a satisfaction in being thus able 
to state, that in a fluid form also, the nitrous acid is 
a medicine, which is applicable to many cases of 
surgery, in which it has not hitherto been usually 
employed* 

3. Inform of powder. 

The only medicine which seems to be adapted to 
this species of ulcer, in form of powder, is the hydrar- 
gyrum nitratum rubrum, all the others being either 
too mild, or more conveniently used in an unctuous 
form. From the violence of its action, it is fitted 
for ulcers of the most indolent kind ; but even to 
nem it should only be occasionally applied, unless 



WITH INDOLENCE. 187 

it is rendered less active, by being intimately mixed 
in different proportions with some inert powder. 

4. In an unctuous form. 

Unctuous applications appear to be better adapt- 
ed to this species of ulcer, than to any other, and 
they have some advantages over medicines in differ- 
ent forms, since the necessary action is no sooner 
produced, and the pus, in consequence of it, secreted, 
than the stimulating application itself is removed 
by the pus from the surface of the ulcer ; and it af- 
terwards serves as an external covering, by which 
the pus is confined in immediate contact with the 
granulations, till the next dressing. The oil becom- 
ing rancid, which is so material an objection to this 
form of medicine in other species of ulcer, is of less 
consequence in this ; as the medicines combined with 
it are always more stimulating in their nature than the 
oil, even in its rancid state. 

In the treatment of ulcers, a great stress has been 
laid upon the bad effects of exposing the surface to 
the external air, as if atmospherical air contained 
something that irritated and excited inflammation. 
In the investigation of this opinion, sufficient proofs 
have been established, that air has no such property ; 
since when the abdomen of an animal is filled with it, 



188 OF ULCERS ATTENDED 

no inflammation takes place. If the cellular mem- 
brane of the body is loaded with it, these parts do 
not afterwards inflame. Nor do ulcers in the throat, 
that must be constantly exposed to the air, heal less 
kindly than those in other parts of a similar struc- 
ture. 

It does not appear that the exposure to air is in it- 
self peculiarly hurtful ; but, from every observation 
I have been able to make, an ulcer does not heal so 
kindly if the parts are disturbed during that process, 
which they must be when much exposed. The na- 
tural easy state, is that of the granulations being co- 
vered by their own matter ; which is only to be re- 
moved occasionally, that means may be used to sti- 
mulate the granulations, to secrete a more perfect 
pus, or such as is best fitted to cover the granula- 
tions during their increase. 

According to this statement, frequent dressings, 
to indolent ulcers, are not only unnecessary, but, 
when the medicines are stimulating, will do harm. 
To apply a dressing once in twenty-four hours is com- 
monly sufficient ; nor should it be done more fre- 
quently, except when the quantity of pus is too great, 
which, in this species of ulcer, seldom happens. 



WITH INDOLENCE. 189 

The ungucntum hydrargyri ; itrati mixed with 
the adeps suilla, in different proportions, according 
to the state of the ulcer, is one of the best applications 
to this species of ulcer, in an unctuous form, in gen- 
eral use. The most common proportion is one 
part of the ointment to three of the lard. It is, 
however, almost always necessary, after using it for 
some time 10 the same ulcer, to increase its strength. 

There is, very commonly, to indolent ulcers, a 
thickened edge, like a welt, all round ; and the skin, 
to some distance from this edge, is of a darkish-red 
colour, arising from an imperfect or languid inflam- 
mation, extending along the skin of the neighbouring 
parts. Such appearances are very readily removed 
by the unguejitum hydrargyri nitrati, and the surface 
of the ulcer, which too often has an ill formed pus, 
mixed with blood and coagulating lymph laid over 
it, under this treatment will form healthy granula- 
tions. 

Upon comparing the effects of this medicine, 
with those of many others that are used in the form 
of ointment, it appears to have more influence over 
granulations, in making them become small and 
healthy, than any of the rest ; and, what may be 
considered as a natural consequence of such a pro- 
perty, the ulcer healed by it is less liable to breakout 



190 OF ULCERS ATTENDED 

again. It has a material advantage also, in admit- 
ting of being made gradually stronger, so that the 
same degree of stimulating effect can be kept up by- 
increasing its strength, as the ulcer from habit be- 
comes less affected by it. 

These are its beneficial effects where it agrees -, 
but there are ulcers of the same kind in particular 
patients, in which it does not answer at all, and 
must therefore be discontinued as soon as that can be 
ascertained. 

The unguentum resinse flavae, and the unguentum 
elemi, are in very general use for ulcers of this 
species ; they have sometimes the balsam of tur- 
pentine, or the balsam copaibse added to them, and 
they are frequently applied hot, to increase their 
stimulating effects, and adapt them to particular 
cases. These are the most common applications 
and their effects are too well known to require much 
being said respecting them in this place. 

It may be necessary to observe, that in general 
the resins and turpentines do not seem to have equal 
powers with the acids and metallic salts, in giving to 
the granulations a healthy appearance ; nor do they* 
appear to give them the same disposition to stand 
their ground when formed. 



WITH INDOLENCE. 191 

This observation may not have been made by- 
other surgeons, in the same way that it is now stat- 
ed, but the effect must have been noticed by those 
who have published in favour of the hydrargyrum 
nitratum rubrum, mixed with such ointments, as a 
means of rendering the cure more permanent. 
When these ointments are used, the same addition 
of the hydrargyrum nitratum rubrum becomes ne- 
cessary, in the proportion of a dram to an ounce ; 
but to be made a little stronger or weaker, accor- 
ding to circumstances. 

Camphor mixed with the unguentum album, or 
any other ointment, may be applied in some varie- 
ties of this species of ulcer, but not so generally as 
the other medicines that have been mentioned ; 
those cases where there is a degree of indolent 
thickening are most likely to be benefitted by it. 

After having enumerated the different medicines 
which may be used with advantage in indolent ul- 
cers, it seems necessary to state again expressly that 
these medicines, in many cases, very soon lose their 
effect ; and that in such instances the great art con- 
sists in changing the application as soon as this cir- 
cumstance is discovered. In regulating such changes 
two things are always to be kept in view ; the one, 
what had been the original state of the ulcer ; the 



192 OF ULCERS ATTENDED 

other, what its present appearance ; by which at- 
tention it will often be found that one ulcer, in the 
progress of the cure, may require to be treated in se- 
veral different ways before it can be made to heal. 
This is so material a circumstance in ulcers of seve- 
ral years standing, that it cannot be too particularly 
noticed. There is another thing to be adverted to, 
that although the ulcer may be in its nature indolent, 
it is liable to temporary changes whenever the con- 
stitution is occasionally affected, and while under 
that influence is to be treated accordingly. If a 
patient who has an indolent ulcer, which is going on 
very well under any stimulating medicine, is attack- 
ed by indisposition, the ulcer will no longer bear the 
former treatment, but requires a milder application ; 
and this milder remedy must be continued till the ge- 
neral system shall have recovered itself, and then 
the ulcer will again bear more active medicines. 

5. Of bandages. 

The great advantages derived in this species of ul- 
cer from an uniform steady compression of the limb, 
is now universally acknowledged, and some mode or 
other of producing this effect is, adopted by almost 
every practitioner. Many surgeons consider a tight 
bandage as the only thing necessary, and adduce a 
number of instances in favour of this opinion ; from 



WITH INDOLENCE. 193 

such partial evidence, however, we are not justi- 
fied in drawing conclusions upon a subject so ex- 
tensive, particularly as the individual cases vary 
more, according to the constitutional peculiarities, 
than any thing immediately connected with the 
ulcer. 

Where tight bandaging is employed at the same 
time that other means are made use of, the bene- 
ficial effects which take place cannot be exclusive- 
ly attributed to either mode of treatment ; it is 
therefore proper to remark, that in all the cases 
brought forward as evidence in favour of the dif- 
ferent applications that have been here considered, 
no species of bandaging was used, but what was 
necessary to keep the dressings applied to the 
ulcer. 

The most effectual mode of compressing the 
limb, and giving the parts an uniform and steady 
support, is by means of the laced stocking : this has 
been long in general use ; it was strongly recom- 
mended by Wiseman more than a century ago ; 
and we must attribute to his recommendation the 
adoption of it in this country, as a common appli- 
cation. 

A roller of calico or flannel applied to the whole 
leg, from the toes upwards, is a very good substi- 



194 OF ULCERS ATTENDED 

tute for the laced stocking, and answers very well, 
when neatly applied. Linen does not make so 
good a bandage for this purpose, as it does not 
yield to the motions of the limb, and is with diffi- 
culty retained upon it, being apt to slip down, from 
the smoothness of its surface. 

6. Of adhesive plaister. 

In the former edition of this work, a mode of 
using the adhesive plaister as a dressing to ulcers 
on the legs was taken notice of.* 

This mode of treatment was first practised by 
Mr. Baynton, surgeon, of Bristol, and the cases 
published of its success were so very satisfactory, 
as to induce me to adopt it, and give it an impar- 
tial trial. 

Since that time, experience has enabled me to 
give ample testimony in its favour, and induces 
me to consider it as one of the greatest and most 
useful improvements in modern surgery. 

This mode of treatment is therefore now consi- 
dered under a separate head. It is particularly 
applicable to indolent ulcers. 

* See Descriptive Account of a new method . of treating 
old Ulcers of the Legs, by Thomas Baynton, surgeon, at 
Bristol. 



WITH INDOLENCE. 195 

The strips of adhesive plaister, spread upon linen, 
are to be about an inch in breadth, or a little 
broader, and long enough to go completely round 
the limb, and afterwards return upon themselves 
for about three inches, so as to keep their hold, 
and become so many firm annular ligaments ; they 
are to be so applied, that their edges overlap, 
leaving no space between them, and the surface of 
the limb, thus covered, is to extend several inches 
both above arid below the ulcer. The effect of 
this practice upon old ulcers with thickened edges, 
where the limb is much swoln, almost exceed cre- 
dibility. In a very few days the size of the limb, 
as well as of the ulcer, is greatly reduced, the un- 
healthy appearance of the granulations wholly re- 
moved, and the matter reduced in quantity, and 
rendered of a better consistence. 

As the plaister is directly applied to the surface 
of the ulcer, at the same time that an uniform and 
steady support is given to the limb, it is not easy 
to ascertain, whether the benificial effects arise 
wholly from the well regulated pressure or not ; 
but, as in practice, the cure appears to be retarded 
by having lint or any other dressing under the 
plaister, there are grounds for believing the com- 
position of the plaister itself is an useful applica- 
tion to such ulcers. 



196 OF ULCERS ATTENDED 

Since this mode of treatment has been publish- 
ed, cases of ulcers have got well under my care by 
its use, which were certainly not to be healed by 
any other mode, that had been tried. 

The following very remarkable instance of this 
kind will support the opinion just stated. 

A gentleman, aged 64, of a full habit of body, 
rather a free liver, with a naturally strong consti- 
tution, six feet in height, while in Gibraltar, in the 
year 1769, had a small ulcer, from the bite of a 
musquito, on the inside of the left leg above the 
ankle ; this was several weeks before it could be 
healed, and in the following winter broke out 
again, and was a still longer time of being healed. 
He went to India, where he remained ten years, 
and in that period it broke out five different times, 
but was never so bad as to confine him. Upon his 
return to England it was in the state of a small 
ulcer, and the whole leg larger and harder than the 
other. It was healed by means of tight bandages, 
and continued well for five years. 

At this time, which was in 1785, a sore broke 
out on the opposite side of the same leg, which 
never healed, continuing sometimes better, at 
others worse, but did not confine him from busi- 



WITH INDOLENCE. 197 

ness till the year 1796, when the pain became vio- 
lent, upon hanging it down, and at all times the 
ulcer was troublesome, often depriving him of 
rest at night ; since that time the ulcer remained 
nearly of the same size, the leg gradually increas- 
ing in size and hardness. Preparations of lead 
always disagreed with the ulcer, warm applications 
soothed the sensations, but the swelling increased 
under them ; a carrot poultice was the only appli- 
cation that was found to give much ease. 

In 1798 the patient came under my care ; the 
ulcer at that time was four inches broad, and 
six long, the edges of the surrounding skin thick 
and welted, and in several parts detached from the 
muscles for nearly an inch beyond the surface of 
the ulcer, which was sloughy, and had no appear- 
ance of healthy granulations, the discharge was 
thin, and so offensive, as to prevent his dining in 
company, the quantity was so great as to require 
dressing three times a day, the pain severe, and ex- 
tending up to the thigh ; the calf of the leg mea- 
sured in its circumference four inches and a half 
more than that of the healthy leg, which was full 
and strong from exercise. 

Under these circumstances the use of the strips 
of adhesive plaister was adopted ; they were ap- 
plied directly to the ulcer, and the calf of the leg 
P2 



198 OF ULCERS ATTENDED 

rubbed with a liniment of equal parts of the ungu* 
entum hydrargyri nitrati and olive oil, allowing 
him to use moderate exercise in his room. On the 
seconddressing the appearance of the discharge and 
surface of the ulcer were much improved; in seven 
days the edges were on a level with the sore, the 
discharge small in quantity, and the granulations 
healthy. In a fortnight he was allowed to visit his 
friends, and take his usual exercise, which appear- 
ed to be attended with advantage. In a month the 
ulcer was only the size of a crown piece, and the 
calf of the leg was diminished two inches and a 
half in its circumference. 

In this state he left town, and went a journey of 
500 miles, rode every day on horseback, and the 
ulcer continued to diminish ; at this time he had 
complaints in his chest, which induced his medi- 
cal attendants to wish the leg not to be healed till 
an issue was made, and the strips of plaister were 
applied more loosely ; under this treatment the 
ulcer again began to spread, but upon the original 
mode being resumed, it diminished in size, and 
healed up ; the leg also became as small as the 
nher. 

The use of the adhesive plaister is particularly 
well adapted to ulcers in the thigh, which are not 
disposed to heal, but to spread into the cellular 



WITH INDOLENCE. 199 

membrane under the skin, forming sinuses; many 
of this kind occur in warm climates, and from the 
looseness of the skin and muscles are very difficult 
to heal. Three instances of ulcers in the thigh, 
which could not be cured in India, haye healed in 
a short time under this mode of treatment, the 
patients using exercise all the time. 



NO directions can be given, respecting which of 
these applications should be first tried in indolent 
ulcers, as a great deal must depend on what had 
been used before, without success ; and in all such 
cases of long standing, many medicines must have 
been previously employed ; the surgeon will there- 
fore be guided by the history of the case, when it 
can be procured. 

The adhesive plaister, the diluted nitrous acid, 
the solution of the argentum nitratum, and the 
unguentum hydrargyri nitrati, are the medicines 
on which it is reasonable to place the greatest de« 
pendance. 



CHAPTER VIII. 

OF ULCERS ATTENDED WITH SOME SPECIFIC DIS- 
EASED ACTION, WHETHER CONSITUTIONAL OR 
LOCAL. 

\J LCERS are met with on the legs of persons 
who labour under constitutional diseases, and also 
of persons who have not any universal disease, 
but are in that state of body which induces parts, 
when injured, to assume some diseased action. 
Such ulcers do not properly come under any of 
the former heads, since they do not heal under 
any of the medicines which are found to answer in 
these different species of ulcer ; they are therefore 
to be considered by themselves. 

When ulcers of these species are distinctly 
marked, they neither resemble, exactly, the irri- 
table nor the indolent, but may be mistaken some- 
times for varieties of the one, and sometimes of 
another ; there is, however, commonly an un- 
healthy appearance of the skin immediately sur- 
rounding the ulcer, which gives to the whole a dis- 
eased aspect, not seen in common ulcers. 



OF ULCERS ATTENDED, &C. 201 

The ulcers which take place in persons whose 
general systems are contaminated by the venereal 
disease, come more frequently under the eye of the 
surgeon than any others attended by a specific dis- 
eased action ; these are therefore mentioned as 
having the character of a diseased ulcer most 
strongly marked. Any such diseased appearance 
has been generally considered as a symptom of 
lues, and ulcers in which it is assumed have been 
too often referred to that cause. This has been 
productive of many serious mistakes in practice ; 
for these peculiar appearances arise from the parts 
being in a diseased state, but are not confined to 
one specific action, and take place in many other 
diseases, as well as the lues venerea. 

As ulcers which are formed on persons, whose 
constitutions are affected by the lues venerea, in 
general require nothing but removing the consti- 
tutional disease by means of mercury, they cannot 
properly be said to belong to our present subject, 
which is more particularly the local treatment of 
ulcers. There are, however, many ulcers that 
were originally venereal, which after the virus 
has been destroyed, assume some new diseased 
disposition. This may happen in different ways; 
it may arise from the state in which the parts 
were left by the original disease, or it may be the 
effect of a long continued course of mercury, and 



202 OF ULCERS ATTENDED WITH 

in many cases a combination of both of them. In 
this view the venereal disease becomes a source of 
many diseased ulcers, some of which are met 
with on the legs. 

Ulcers attended by disease occur also in per- 
sons of scrofulous habits, in those whose bodies 
are weakened by a long continued intemperance of 
different kinds, in those disposed to cancer, and in 
many instances arise from causes, with which we 
are little, if at all, acquainted. Were there any 
means of ascertaining all the diseases of the sys- 
tem, or of the parts, which produce these un- 
healthy or ill-conditioned ulcers ; could they be 
distinguished with any degree of accuracy from 
one another, it would be right to consider them in 
some order connected with their causes or appear- 
ances ; but this, till our knowledge of ulcers shall 
be greatly improved, cannot well be done. At 
present it will not be attempted to do more, than 
to state the medicines which may be used with 
advantage in ulcers of this description : pointing 
out, under the head of each medicine, such cir- 
cumstances as may assist the judgment in deter- 
mining which are the most proper cases for their 
use. 

In ulcers in general, the principal dependance 
for the cure must rest upon the local applications ; 



SOME SPECIFIC DISEASED ACTION. 203 

as the complaint, although under the influence of 
the system at large, and varying in its appearance 
according to the peculiarities of the general sys- 
tem, is still a local complaint ; but when they arise 
from a specific disease, whether it is in the system 
or in the part, it is natural to suppose, that what- 
ever medicine can relieve the specific disposition, 
will do it, in many cases, with equal advantage 
through the medium of the system, as when locally 
applied ; and even where used internally without 
the same degree of efficacy, it must, if it acts at all, 
be generally supposed to assist in the cure. 



1. OF THOSE ULCERS WHICH YIELD TO MERCURY. 

IT is not meant, as has been already stated, to 
consider those ulcers which are immediately con- 
nected with the venereal disease, but such only as 
are produced by other diseases of the general sys- 
tem, or of the parts, which yield to the effects of 
this medicine. 

It was natural, when the beneficial effects of 
mercury in the venereal disease were first dis- 
covered, to suppose that every complaint which 
yielded to mercury must be venereal. It was, 
however, to be expected that obersations, accu- 



204 OF ULCERS ATTENDED WITH 

rately made, would soon ascertain that this active 
medicine is capable of producing salutary effects 
in many other diseases. Yet a long time elapsed 
before this was generally allowed. 

Even now, when it is universally admitted that 
mercury, employed through the medium of the 
system, is the most efficacious medicine in inflam- 
mations of the liver, and in diseases of many of 
the other viscera, surgeons very unwillingly give 
it credit for the cure of ulcers that are not vene- 
real ; but are inclined to suppose every ulcer that 
yields to such treatment arises from that disease. 

This is by no means true ; for many ulcers, un- 
connected with the venereal disease, which re- 
ceived no benefit from other medicines, shall heal 
under a mercurial course, or yield to mercurial 
applications. In some cases the ulcer has remain- 
ed stationary during the use of the mercury, but 
as soon as it was left off, has put on a more kindly 
appearance ; the mercurial course having pro- 
duced so great a change in the constitution, as 
to destroy the disposition which had kept the ul- 
cer from healing. 

Such ulcers are, in general, in their appearance 
allied to the indolent kind, but have some diseased 
disposition peculiar to themselves. Mercurial 



SOME SPECIFIC DISEASED ACTION. 205 

frictions are in these cases to be preferred, as it is 
a material object to impair the constitution as little 
as possible, by leaving the stomach undisturbed, and 
in a state to take nourishment. 

There are ulcers on the instep and foot, with a 
very thickened edge, and a diseased state of the sur- 
rounding skin, approaching in their appearance to 
what is called Elephantiasis. These are frequently 
met with in servants of opulent families, where they 
had led an indolent life, and fed upon a luxurious 
diet. In cases of this kind fumigation with the 
hydrargyrus sulphuratus ruber has healed the ul- 
cers, and resolved, in a great degree, the swelling of 
the surrounding parts. 

The mercurial ointment, either made by calomel 
and hog's-lard, or the unguentum hydrargyri mitius, 
mixed with camphor, answers, in some cases, better 
than any other application. 

Camphor, in general, renders the mercury more 
active, than when employed alone ; and the mouth 
has been frequently known to be affected by an ap- 
plication of this kind to a small surface, when the 
mercurial ointment, applied to a much larger extent, 
has produced no such effect. 



206 OF ULCERS ATTENDED WITH 

The hydrargyria muriatus diluted with water (to 
which a small portion of spirit has been added) in 
the proportion of a grain to an ounce, is a very use- 
ful application to many ulcers with a diseased as- 
pect, more particularly those that are superficial, 
with a thickened edge, and appear to be principally 
confined to the skin. 



2. OF ULCERS WHICH YIELD TO THE'USE OF DIF- 
FERENT PREPARATIONS OF THE CONIUM MACU- 
LATUM, OR HEMLOCK, 

THE inspissated juice of the conium macula- 
turn internally employed, is by some practitioners 
supposed to be entirely inert ; while by others it is 
believed to have considerable powers over many dis- 
eases* From these opinions, so diametrically oppo- 
site, and both taken from actual observation, it 
would seem that its effects are very precarious. I 
confess myself to be by no means warm in its fa- 
vour, for though it is sometimes of service in local 
complaints, it has so often failed, that much reli- 
ance cannot be placed upon it as an internal medi- 
cine, in diseases connected with surgery. 



SOME SPECIFIC DISEASED ACTION. 207 

As an external application, the conium macula- 
turn is a much more certain medicine ; and I do not 
hesitate to declare myself convinced, that there are 
cases of diseased ulcers on the legs which are cured 
by it more readily than by other means. 

The ulcers which are most generally benefitted 
by it, from their appearance, would be classed with 
the irritable ; but there is in the surrounding parts a 
degree of thickening, which must be attributed to 
some specific diseased action. These ulcers are 
met with in the neighbourhood of the ankle joint, 
and the joint itself is enlarged. They sometimes 
occur upon the ligaments of the joint of the knee, 
but less frequently. From their situation, and the 
enlargement of the joint, they may be suspected to 
be scrofulous ; but from their sensibility they must 
be considered as an uncommon variety, if they 
really belong to that disease. In such diseased ul- 
cers the conium maculatum takes off the pain, re- 
duces the swelling of the joint, and seems to coun- 
teract the diseased disposition, whatever may be its 
nature. 

In many ulcers that are truly scrofulous, the ex- 
ternal applications of the conium maculatum are 
productive of the greatest advantage particularly in 
those attended with irritability. 



ZQ8 or uLcers attended with 

The conium maculatum admits of being employed 
in three different forms, but only two of them are 

n general use. 

The decoction is used as a fomentation, which is 
a very advantageous form, in those cases which are 
attended with pain ; since the warmth assists in 
soothing and alleviating the symptoms. 

It is used in the form of poultice, which has an 
advantage, as it adfflits of being much longer con- 
tinued to the ulcer. The decoction of which the 
poultice is made should be much stronger than is 
commonly directed. Eight bundles, or four hand- 
fuls, of the dried herb, and a greater quantity of 
fresh leaves in proportion, should be boiled in a 
quart of water to a pint. A poultice made with a 
weak decoction has frequently been used without 
the smallest benefit ; but when the strength of the 
decoction was increased, the ulcer shewed evident 
signs of amendment. Where the weight of the 
poultice proves oppressive to the limb, the decoction 
may be applied upon lint to the ulcer. 

The inspissated juice of the conium maculatum 
admits readily of being formed into an ointment ; 
but although several trials have been made with 
it, the results were not in its favour as an external 
application. 



SOME SPECIFIC DISEASED ACTION, 209 



3. OF ULCERS WHICH YIELD TO THE APPLICATION 
OF SALT WATER. 

Salt water is an exceedingly good application in 
many scrofulous ulcers, some of them being more 
readily cured by it than by other applications. The 
form of poultice is most commonly employed \ but 
in many cases of ulcers on the legs, keeping the part 
immersed in tepid salt ..water, for fifteen minutes, 
twice a day, appears to be preferable to any other 
mode. Several small ulcers have got well under 
this treatment in a fortnight, which had resisted the 
effects of internal medicines, and many different 
external applications, for six months ; nor did the 
ulcers return afterwards in the course of several 
years. The same mode has been used with large 
ulcers, and frequently with success. In scrofulous 
ulcers on the legs and feet, the salt-water poultice 
sometimes brings out pimples on the skin, so that 
the application cannot be continued. When this is 
the case, adding equal parts of decoction of poppies 
takes off this unpleasant effect ; and after the skin 
has been for some time accustomed to the salt water 
in a diluted state, it will bear the salt water bv 
itself. 



210 OF ULCERS ATTENDED WITH 

In such cases the foot or leg, at the times the poul- 
tice is to be changed, will receive benefit by being 
immersed for ten minutes in tepid salt water. 

In some superficial ulcers, attended with a thick- 
ening of the skin, that have been in that state for 
months, the application of tepid salt water has pro- 
duced a cure. 

When there is an unusual coldness in the limb, 
without any tendency to mortification, the tepid salt 
water may be used with great advantage ; it brings 
a glow upon the skin, and rouses up the actions of 
the parts, so as to give an ulcer which had for some 
time been in an inactive state, a disposition to heaL 
These cases occur in tall thin men who are unhealthy, 
and advanced in life. They are also met with in 
young women who are very weak and unhealthy ; 
the whole system in such cases is apparently defec- 
tive, not having sufficient energy to do more than 
carry on the functions of life, and being therefore 
unable to support the effects of disease. 

Where the leg has a tendency to become anasar- 
cous,the application of tepid saltwater is sometimes 
found entirely to remove that disposition. 



SOME SPECIFIC DISEASED ACTION. 211 



4, OF ULCERS WHICH YIELD TO THE USE OF THE 
ARGENTUM N1TRATUM. 

There is a species of ulcer which does not appear 
to go deeper than the cutis, but spreads in all 
directions, producing ulceration on the surface of 
the skin, and frequently extends in depth through it's 
whole thickness, or nearly so. This diseased dis- 
position, whatever it is, does not remain in the parts 
which have ulcerated, but only on the edge of the 
skin, where the ulcer is increasing, for the surface 
first affected heals while the skin beyond is in a state 
of ulceration. 

This description applies nearly equally well to 
the ulcers produced by three separate diseases, to 
all of which the soldier is peculiarly liable. One is a 
leprous eruption, most commonly met with among 
the impressed men brought from Ireland. Another 
is the consequence of buboes, which from their long 
continuance after the venereal virus has been de- 
stroyed, dispose the skin to take on this disease. 
The third is a disease of warm climates, commonly 
called the ring- worm. All of these, as far as my 
experience enables me to form an opinion, yield 



212 QF ULCERS ATTENDED WITH 

more readily to the solution of argentum nitratuni 
applied to them in different proportions, than to any 
other local treatment. 

The disease met with among the Irish recruits 
is evidently of the leprous kind, as it is communi- 
cated by infection ; and, in those instances that have 
come under my care, was received by lying in bed 
with persons affected by it. Under these circum- 
stances, a vulgar prejudice of its only affecting parts 
similar to those that had the disease, is very readily 
explained, for such similar parts in bed are the most 
likely to come in contact with each other. 

It affects in general the breast, back, and legs ; 
it shows itself by a swelling like a large boil, with a 
pale red margin, extending for some way all round ; 
a reddish black scale forms on the top, the boil be- 
comes extremely painful, and itches ; the scales fall 
off, exposing a foul ulcer, which discharges a foetid 
limpid fluid, and excoriates the surrounding skin, 
producing ulceration wherever it comes in contact : 
in this way it spreads over the greater part of the 
limb, and in some instances over a considerable 
portion of the body ; the parts first affected healing, 
while the disease is extending itself to those be- 
yond. 



SOME SPECIFIC DISEASED ACTION. 213 

These ulcers remain open sometimes three, four, 
or even six months, and then heal up, leaving a 
cicatrix similar to that which remains after the 
small pox ; those cicatrices often break out again in 
the spring in the same way that the disease first began, 
by forming a boil which becomes an ulcer, and 
spreads as it did before. In the very hot weather 
the pain and quantity of discharge are the greatest ; 
so that in the month of June the disease is the most 
virulent, and in the autumn subsides. 

The symptoms are aggravated by the use of 
spirituous liquors, by feeding on salt provisions, 
and catching cold ; under any of these circumstan- 
ces the ulcers are more inflamed and the pain more 
violent. 

A number of cases of this kind came under my 
care in the year 1778, at the Naval Hospital at Ply- 
mouth, being brought from Ireland, among the men 
impressed for the use of the navy. Mild applica- 
tions did not answer ; more stimulating medicines 
gave relief ; and the solution of the argentum nitra- 
tum appeared upon the w T hole to be the best adapted 
to this disease. 

The disease in the skin produced by the effects 
of very irritable buboes, in constitutions broken 



214 OF ULCERS ATTENDED WITH 

down by mercury, is very similar in its progress to 
that which has been described ; it is, however, more 
violent, the ulceration going deeper than the skin, 
which makes it more painful ; it spreads in some 
cases down the greater part of the thigh, and up- 
wards almost round the body. The new skin 
which forms is readily disposed to ulceration, and 
the parts break out again very commonly in the 
spring. The discharge is of a thin acrid kind ; and 
ajs it excoriates the surrounding skin, there is little 
doubt but that it would affect the skin of another 
person. 

In several cases of this kind, a variety of appli- 
cations have been tried, but none of them agreed 
with the skin so well as the solution of the argen- 
tum nitratum ; all preparations of mercury did 
harm ; no unctuous application answered, so that 
it was always necessary to return to the argentum 
nitratum ; and by steadily persevering in its use, 
even in the worst of them, a cure was nearly effect- 
ed, after a continuance of the disease for nine 
months, previous to its being applied. 

The ring-worm is considered as a disease of 
warm climates ; and in the stage where an ulcer is 
formed, it certainly is confined to hot countries ; 
it is however, met with in a less degree in the warm 



SOME SPECIFIC DISEASED ACTION. 215 

season in England. It is supposed to be infectious, 
and always to be caught in that way ; that it is so 
generally, there can be no doubt, but it also arises 
very commonly without any infection : this how- 
ever, probably happens where the skin is very rea- 
dily affected by the disease. That infection is not 
necessaiy for the production of the ring-worm, is 
proved by the following instances where it arose 
spontaneously. 

In the summer 1779, while at Plymouth, I was 
consulted by an officer in the 75th regiment, at the 
desire of Mr. Venour, who was then surgeon to it, 
for a complaint on the skin of the upper part of the 
thigh, which appeared to be an uncommon disease, 
and did not yield to any applications that were 
made to it. I felt myself equally at a loss in what 
view to consider it ; mercury was used in different 
forms, but without any good effect, and in the au- 
tumn it very gradually went off. 

About a year after seeing this case I embarked 
for the West Indies, and as soon as the ship had 
got within the tropics, found myself more oppressed 
and irritated by the heat than most of the Europe- 
ans on board, and to my astonishment found a simi- 
lar complaint had taken place to that under which 
the officer had laboured at Plymouth* To allay 



216 OF ULCERS ATTENDED WITH 

the extreme pain and itching it produced, cold wa- 
ter was frequently applied to the part, which kept 
it very cool ; under this treatment it went off, but 
but not for several weeks. Upon my arrival in 
the West Indies the disease returned, aud was as- 
certained to be the ring-worm, so common in that 
country, which it was impossible for me or the of- 
ficer in the 75th regiment at Plymouth, to have re- 
ceived by infection. 

The ring-worm begins by an efflorescence on the 
skin, a little raised above the natural level, which 
spreads from a centre ; when the disease increases 
in violence, the margin of the circle is raised into a 
welt, and the surface contained within it appears 
scurfy ; the welt becomes covered with a scab which 
falls off, exposing an ulcerated ring, commonly not 
more than a quarter of an inch broad ; the ulcer- 
ation spreads outwardly, and heals towards the cen- 
tre, so that in general the breadth of the ulcera- 
tion is nearly the same, although the circle is becom- 
ing larger and larger. It seldom becomes of any 
depth, being entirely confined to the cutis ; but in 
the worst cases it appears to extend through its 
whole thickness. In this stage it must be classed 
among the diseased ulcers, and among those of a 
very distressing kind, as the painful symptoms are 
exceedingly violent. The discharge is not pus, but 



SOME SPECIFIC DISEASED ACTION. 217 

a thin watery fluid, of a very acrid nature, which, 
by its virulent properties, most probably extends the 
disease along the skin. 

In the East Indies, the application in use to it, in 
this stage, is vinegar, saturated with borax. The 
natives employ the juice of some plants, which is 
sold as a secret medicine ; it is made by an Hindoo 
doctor at Vizagapatam, and sold at the different 
presidences in India. This medicine is of a very 
acrid nature, giving the patient excruciating pain, 
but removes the disease in a very short time. 

The solution of the argentum nitratum .answers 
in the milder cases, and there is little doubt of its 
being equally successful in those that are more 
severe. 



218 OF ULCERS ATTENDED WITH 



5. OF tfLCERS WHICH YIELD TO THE USE OF 
ARSENIC. 

ARSENIC has been applied externally, in cases 
of cancer, by a number of empyrics, as a caustic ; 
but from the violence of its effects, regular practition- 
ers have in general been afraid to employ it in cases 
of surgery. It is, however, a medicine that may 
be used with safety, both internally and externally, 
in many diseased ulcers, with the gre?itest advan- 
tage. 

Those ulcers in which I have been led to employ 
it are named, from the virulence of their disposition, 
noli me tangere ; and are very nearly allied to can- 
cer ; differing from it in not contaminating the 
neighbouring parts by absorption, but only spread- 
ing by immediate contact. 

Ulcers of this kind differ exceedingly from one 
another in their degree of virulence ; but they are 
all so far of the same nature, that arsenic in general 
agrees with them, and puts a stop to their progress, 
while they are aggravated by milder dressings. 



SOME SPECIFIC DISEASED ACTION. L 2VJ 

I have been in the habit, for many years, of using 
arsenic externally to such ulcers, and its effects en- 
couraged me to continue this practice, but did not 
authorise giving it internally with this view, lest 
the quantity necessary to be of any service might 
prove hurtful to the coats of the stomach. I was, 
however, induced to try it some years ago in St. 
George's hospital, in the following case, in which 
nothing could be well applied to the part itself. 

A woman, 65 years of age, came into St. George's 
hospital on the 15th of June, 1796, with an ulcer 
on the side of the tongue, of three months continu- 
ance. It was foul, and spreading backwards to the 
root of the tongue, was extremely painful, and the 
ulcer had an offensive smell. It was out of the 
reach of external application. Finding no advan- 
tage from the use of the extract of the conium ma- 
culatum, which was given in large doses, it was 
thought right to try the solution of white arsenic in 
boiling water. She took, at bed time, five drops for 
a dose : this made her very sick ; next night three 
drops were given, which did not disturb the sto- 
mach ; this dose was continued for four successive 
nights, and as the stomach was very quiet, the num- 
ber of drops was again increased to five, which 
were now found to agree very well. The ulcer was 
evidently better, and at the end of three weeks, 



220 OF ULCERS ATTENDED WITH 

from the time the arsenic had been used, was much 
diminished in size. The dose was increased to six 
drops ; and, in a fortnight more, the ulcer was 
completely healed. The arsenic in this case could 
not act locally, as the ulcer was not situated upon a 
part of the tongue to which it could apply itself in 
the act of swallowing ; and if it had, the time of ap- 
plication must have been too short to produce much 
effect. 

The success attending this case induced me to try 
the internal use of arsenic for an ulcer upon the 
side of the nose of a young woman, which had 
much the appearance of the noli me tangere. No- 
thing was externally applied ; the whole treatment 
consisting in the internal use of arsenic ; and in the 
course of a few weeks the nose was nearly healed. 

These, not being cases of ulcers on the legs, may 
be considered as foreign to the present subject; 
but they are here introduced, with a view to justify 
the internal use of arsenic in those ulcers on the leg, 
which receive benefit from its external application ; 
since they show, in the most unequivocal manner, 
that such practice is in itself not only safe, but capa- 
ble of being attended with great advantage. 



SOME SPECIFIC DISEASED ACTION. 221 

To ulcers of an untoward appearance on the legs 
arsenic may be used, both internally and externally, 
with success. 

The cases to which this treatment is peculiarly 
applicable are those of the fungated ulcer. They 
ire met with in the calf of the leg, and on the sole 
of the foot, shooting out a fungus from the surface, 
which is entirely different from common granula- 
tions : the new formed substance is radiated in its 
structure, the bottom of the ulcer being the central 
point, and the external surface (which is always 
increasing) the circumference. This fungus is 
very tender in its substance, and bleeds, if- the 
slightest violence is committed on it. This dis- 
ease in its origin sometimes appears like a scrofu- 
lous affection of the metatarsal bones of the foot ; 
but the enlargement of the parts exceeds what com- 
monly is met with in scrofula, ulceration takes 
place upon the skin, and a fungus shoots out, show- 
ing, for the first time, the nature of the disease, 
Whether such cases are originally scrofulous, and 
afterwards assume this new diseased disposition 
it will be very difficult to determine, but their re- 
maining for a year before the fungus shows itself 
renders it highly probable. The same disease takes 
place in the testicle. 

T 2 



222 GF ULCERS ATTENDED WITH, &C„ 

There appear to be two kinds of this disease, 
one which is poisonous, and capable of contamina- 
ting the lymphatic glands in the course of absorp- 
tion ; the other not. There is no mode by which 
these two species can be distingusihed in their ear- 
lier stages ; and the first kind is not to be removed 
by this, or any other application at present known : 
it is therefore only in the second kind that the ar- 
senic is capable of effecting a cure. This medi- 
cine should, however, be used in all cases not as- 
certained to be poisonous. 

The solution of arsenic, which I have always 
used, is made by boiling white arsenic in water for 
several hours in a sand heat, and taking this satu- 
rated solution for use. When given internally, the 
dose is from three drops to ten ; when externally 
applied, a dram is diluted with lb. ij of water ; 
and this solution is gradually made stronger, as the 
parts become accustomed to it, till it is of double 
strength. This solution is either applied on lint, or 
made into a poultice* 

In ulcers connected with diseased bone, which 
prevents them from healing, the luxuriant granula- 
tions rise up round the orifice leading to the bone, 
and require being destroyed by some escharotic j 
the solution of arsenic answers this purpose better 
;han anv of those in common use* 



CHAPTER IX, 

OF ULCERS ATTENDED WITH A VARICOSE STATE 
OF THE VEINS OF THE LIMB, AND THE ADVAN- 
TAGES DERIVED IN SUCH CASES FROM INCLU- 
DING THE VENA SAPHENA IN A LIGATURE. 

KJ lcers occur in many patients, but more fre- 
quently in tall people, on the inside of the leg, just 
above the ancle. They have their origin from 
some accidental cause, and when once they take 
place are difficult of cure, and almost always break 
out again. 

This ulcer resembles in its appearance those of 
the indolent species, rather of a mild kind ; but if 
the state of the limb is examined, it will be found 
that the branches of the superficial veins which 
form the vena saphena are, many of them, preter- 
naturally enlarged, and the vena saphena itself is 
extremely large. It is this enlargement in the veins 
which prevents the ulcer from being healed. 

This species of ulcer is seldom very deep ; when 
it spreads, it is generally along the surface ; its shape 



224 OF ULCERS ATTENDED WITH 

is commonly oval, the ends of the oval pointing 
vertically. The edges of the surrounding skin are 
commonly neither thick nor irregular, but are im- 
perceptibly lost in the ulcer. The pain which it 
gives is seldom from the surface, for pressure does 
not increase it ; but there is an aching uneasy sensa- 
tion in that part of the leg. This pain is deeper 
seated than the surface of the ulcer, and very often 
extends up the leg in the direction of the veins ; and 
is increased to a very great degree, if the limb is 
long kept in an erect posture. 

The ulcer commonly increasing in the course of 
the veins encourages an opinion, that inflammation 
and ulceration in ulcers in general run along the 
internal surfaces of the smaller veins, which open 
upon the ulcerated part, and that this is the common 
cause of their increase. There does not appear any 
other obvious reason why the ulceration should ex- 
tend upwards, contrary to what happens in ulcers 
on the leg in general, especially as it will be found, 
in the course of these observations, that there is, at 
that time, no disease whatever in the part itself. 

That ulcers do, in some instances, spread in the 
course of the veins, may be illustrated in the liver, 
where the veins coming from the ulcer have been 
found to have their orifices perfectly open ; the ad- 



A VARICOSE STATE OF THE LIMB. 225 

hesive inflammation not having united their sides 
together, and the internal surface for some way ap- 
pearing inflamed. 

The enlargement of the veins of the leg, par- 
ticularly the superficial veins in middle aged and 
old people, happens so frequently, that no one who 
has attended to the subject can be ignorant of it. 
When once this disposition in the veins has begun, 
it generally goes on increasing, and the limbs be- 
come less able than usual to bear violent exercise, 
or to sustain the body long in the erect posture. This 
is so often met with where there are no ulcers on 
the leg, that it must be considered as a diseased 
relaxation of the coats of the veins, of which the 
immediate cause is, at present, unknown. 

Although ulcers on the legs, therefore, cannot be 
said to produce this enlargement of the veins ; yet, 
when once an ulcer takes place in such a limb, it 
seems, by making it weaker, to increase that dis- 
position, or at least to render the progress of the 
complaint more rapid. 

An ulcer, in whatever way produced, upon a limb 
in this state of enlarged veins, is more difficult to 
heal than otherwise it would have been ; is more 
liable to break out again after it has cicatrized, and 



226 OF ULCERS ATTENDED WITH 

too often cannot for many years be made to heal at 
all. 

This species of ulcer is very common in the 
army. I have very often seen it in non-commis- 
sioned officers, and am led to believe that grenadiers 
are, from being taller, more liable to it than the men 
in the batallion or light infantry companies. It is 
an ulcer which external applications rarely can 
remove ; and many men, on this account, are either 
invalided, or, from a consideration of their former 
services, or, of some particular good qualities, are 
placed in situations unconnected with the effective 
strength of their regiments. The disease in the 
veins, which prevents those ulcers from healing, is 
frequently brought on by the fatigues and changes 
of climate to which soldiers are subject, and by 
which their general health is sometimes greatly 
impaired. 

The officers in the army, from the same circum- 
stances, are more liable to this complaint than any 
other description of men in the higher orders of 
society. In them, where no accidental cause has 
produced an ulcer, it is not noticed ; and when ulcers 
have been formed, they may, by great attention, be 
healed, so as only to break out occasionally ; which, 
when it happens, is supposed to arise from the im- 



A VARICOSE STATE OF THE LIMB. 227 

paired state of their bodily health, being seldom 
referred to the real cause. 

This species of ulcer, although difficult to heal, 
has not been considered the opprobrium of surgery, 
because in general the ulcer is not very large, nor 
is its appearance such as to alarm the mind of either 
the patient or the medical attendant. But, from its 
not getting well under the use of different medicines, 
it has been productive of considerable embarrass- 
ment to the mind of the surgeon, and has taken 
from him the necessary confidence in the treatment 
of other ulcers, more within the influence of external 
applications, so as materially to retared the improve- 
ment of this branch of surgery. 

This happened to myself, and many were the 
mortifications met with in my attempts to heal such 
ulcers, before the peculiarity which renders them a 
distinct species was ascertained, nor was it unnatu- 
ral to draw conclusions very unfavourable to the 
healing powers of the medicines which had been 
used without effect, while ignorant of the circum- 
stances by which they had been counteracted. 

Cases of this kind show, in the clearest point of 
view, that we are not wholly to give up the use of 
medicines, because in some cases they have not an- 



228 OF ULCERS ATTENDED WITH 

swered, since the want of sucess most prabably arises, 
not from any inefficacy in the medicine, but from 
our misapplication of it. 

It is this species of ulcer, which, from its great 
backwardness to heal, has given the idea of its being 
a- natural drain from the constitution, which it was 
improper to dry up ; and the strong argument ad- 
vanced in favour of this opinion has been, that 
whenever it was healed, it broke out again, and the 
patient was full as easy while the ulcer was open, as 
when it was closed, if not more. This may at first 
appear extraordinary, but can be readily explained ; 
since the pain, in such cases, arises more from the 
distended state of the veins, than from the ulcer ; 
and the patient will naturally be led to use more 
exercise when the ulcer is healed, which will keep 
the veins in a more uneasy state. 

This is the species of ulcer in which tight band- 
aging to the leg is particularly applicable, and roll- 
ing the whole limb, from the toes to the knee, is 
found to be attended with the greatest advantage. 
It is to be understood, that the tight bandaging is 
not immediately applicable to the ulcer itself, as it 
will appear that it is immaterial in what way the 
management of the ulcer is conducted ; and it is 
probable that the success of tight bandaging in ul- 



A VARICOSE STATE OF THE LIMB. 229 

cers attended with varicose veins, has led to the use 
of compression in other species of ulcers, wherein 
it has proved hurtful ; not being suited to the state 
of the limb, which often is unable to bear any thing 
tight upon it. 

Soldiers who have the slightest disposition to a 
varicose state of the veins, whether there is an ul- 
cer on the leg or not, should have their gaiters so 
made as to answer the purpose of a tight bandage, 
which may be readily done by having them very ac- 
curately fitted to the leg; for this purpose those 
made of woollen cloth will answer best, as its elas- 
ticity allows it to yield to the motion of the muscles, 
and always preserves an uniform compression. 

A laced stocking is a most useful application, and 
if it could be worn without inconvenience, probably 
no other mode of treatment would be necessary ; 
but it too often happens that the patient is unable to 
bear the necessary degree of general compression 
for any length of time, and therefore after using it 
for some weeks, is obliged to leave it off. 

Having found, in some cases of ulcers under these 
circumstances, that no local treatment whatever 
would produce a cure, and that the ulcer healed un- 
der the simplest applications when the laced stocking 



230 Or ULCERS ATTENDED WITH 

was used ; my attention was very naturally diverted 
from the consideration of the ulcer itself, to that of 
the veins of the leg. 

The case which most particularly impressed my 
mind with this idea, was the following. 

A. B. a workman employed by Mr. Ramsden the 
optican, had an ulcer on the leg, for which he was 
admitted into one of the Royal Hospitals in London ; 
he remained there for several months, but the 
ulcer baffled the skill of the surgeon to whose care 
the patient was entrusted, and he left the hospital 
nearly in the same state in which he entered it. As 
the man was a valuable workman, Mr. Ramsden 
was very solicitous about his recovery, and begged 
me to give him my advice. The man happened to 
have been standing for some time before his leg was 
examined, which gave me an opportunity of per- 
ceiving the veins to be extremely varicose, and pre- 
ternaturally enlarged ; the use of the laced stocking, 
was therefore advised as a support to the veins ; to 
this he immediately had recourse, and very soon, 
got well, the ulcer being dressed with the most sim* 
pie ointment. 

This case, with many others, led naturally to the 
adoption of the laced stocking, not as a general prac- 



A VARICOSE STATE OF THE LIMB. 231 

tice in all old ulcers on the leg, but in all those 
where the veins of the limb were enlarged ; it also 
prepossessed me in favour of tight bandaging in 
cases of ulcers on the leg. 

On putting it to the test as a general practice, it 
appeared, that there are many people whose legs 
can neither bear the laced stocking nor a tight band- 
age of any kind, and that instead of deriving advan- 
tage from such applications, the ulcer, in these sub- 
jects, becomes worse ; or if it gets better, the limb 
becomes uneasy that the patients are obliged to leave 
off the bandage. 

As an instance of the first kind, the following case 
is mentioned. A gentleman put himself under my 
care for a small ulcer on his leg, which he had in 
vain attempted to heal by the common applications. 
An ointment composed of one part of the unguen- 
turn hydrargyri nitrati mixed with three parts of 
hog's lard, was applied to the ulcer, and the leg 
rolled as tight as the patient could bear. He had 
no sleep all night, and the ulcer looked w T orse next 
day. This was not attributed to any part of the 
treatment, and therefore it was continued. The 
ulcer became still worse : he now mentioned that 
the tight bandage gave pain, that 15 years before he 
had an ulcer on the same leg, that Mr. Moffat the 



"Zo2 OF ULCERS ATTENDED WITH 

surgeon had bound up in the same way, and that the 
sffrct was the same. The bandage was left off, 
and in a few days the ulcer got quite well. Since 
that time several instances of the same kind have 
occurred to me, and indeed there are many people 
who in health, cannot bear the slightest compression 
on the leg. 

From these examples it is evident that no abso- 
lute rule of practice can be laid down for all cases ; 
the peculiarities of constitution being such as to re- 
quire being considered apart. As, however, those 
patients who cannot bear tight bandaging at all, are 
but few, they must rather be looked upon as excep- 
tions, and uncommon cases, than as affording any 
argument against the general treatment ; but it does 
also happen that even in those cases where the veins 
are enlarged, the limb too often cannot bear com- 
pression for any length of time. 

As the tight bandage and laced stocking, the only 
modes of compressing the veins recommended to 
us, and sanctioned by general practice* in many in- 
stances cannot be adopted, and in others are attended 
with great inconveniences, and consequently are 
seldom uniformly complied with, it is right to con- 
sider in what other way the same effect can be pro- 
duced. 



A VARICOSE STETE OF THE LIMB. 233 

The remarks which have been made upon tight 
bandaging must, be familiar to every one who has 
considered this subject with any degree of attention* 
They have not been stated under the idea of con- 
veying any new information ; on the contrary, the) 
are rather meant as a justification of my not having 
been satisfied with that practice in all cases. They 
show, at the same time, that it had not been passed 
over, but had a fair trial given it ; and after a careful 
investigation of its effects, it had been given up, and 
the failures which occurred had led me to endeavour 
' to find out a substitute, which might be free from 
its disadvantages. 

In considering the mode by which the varicose 

veins prevent an ulcer from healing, it appeared to be 

most readily accounted for in the following manner. 

That in consequence of the size of the vena saphena, 

and its numberless convolutions, the return of the 

blood from the smaller branches is so impeded, as 

to retard the circulation in the smaller arteries, and 

to interfere with their action in forming healthy 

granulations. This observation is, in some measure, 

confirmed by the following circumstance. In cases 

of ulcers attended with weakness, on the lower pa v t 

of the leg, the granulations while the patient lies in 

an horizontal position, appear florid and healthy ; 

but if he is made to stand up, and continues in that 
u 2 



234 OF ULCERS ATTENDED WITH 

posture only for a few minutes, they become of a 
deep dark-red colour, and frequently bleed. This 
change can only arise from the increased resistance 
which the blood encounters in its return through the 
veins of the limb, when the body is- erect. 

An enlargement of the veins produces also 
another effect. The coats of the vessels and the 
valves become thickened, which renders the valves 
less pliant, they do not occupy the whole area, and 
therefore are no longer of any use ; and from this 
defect the whole length of the column of blood in the 
vena saphena is, in the erect position,, pressing upon 
the contents of the smaller veins, so as to dilate them 
still more and more, and keep the limb always in a 
weak state. 

Under these circumstances, it appeared to be an 
object of no small importance to take off a part of 
the pressure of this column of blood, which would 
probably allow the parts lower down to be in a more 
easy state, and better able to recover themselves ; it 
might also prevent the veins from being still more 
dilated, and so far stop the progress of the disease 
in these vessels. 

The only mode of doing this, that suggested it- 
self, was that of making an artificial valve, by pass- 



A VARICOSE STATE OF THE LIMB. 235 

ing a ligature round the vena saphena, as it pas- 
ses over the knee joint, and obliterating the vein at 
that part. The reason for applying the ligature 
upon this particular portion of the vein is, that just 
at that part the branches from the different parts of 
the leg unite and form a common trunk, and as it is 
the preternatural enlargement of some, or all these 
branches, which constitutes the principal part of the 
disease, the most effectual mode of taking off the 
weight of the column of blood contained in the 
common trunk will be by obliterating it, as near as 
possible to the termination of those branches into it. 

The practice of taking up veins is not new ; it 
was in use by the older surgeons in cases of vari- 
cose veins, and in one case was practised by Mr. 
Hunter. In that particular case several branches 
were separately taken up, which increased the pain 
of the opei ation, and made it more tedious ; but 
the man was much benefitted by it. In that instance 
this mode of treatment was adopted with the view 
of alleviating the disease in the smaller veins, 
without any reference to the cure of ulcers on the 
leg : and in the practice of the older surgeons, if 
the dilated branches only were taken up, it could 



236 OF ULCERS ATTENDED WITH 

not succeed. Its failure was probably the cause of 
its falling into disused 

The present intention, as well as the mode of 
effecting it, is somewhat different. The principal 
object is the healing of the ulcer ; and this will be 
found of no small consideration, when it is known 
that ulcers of this description, although not so pain- 
ful and troublesome as ulcers in common, are at- 
tended with an uneasy sensation in the course of 

*, " The cure of these ulcers with varix is either real or pal- 
liative. The real or perfect cure proposed by the ancients, I 
have delivered in the chapter of a simple varix : it is by mak- 
ing an incision in the skin, and taking up the vein, and tying it, 
&c* But this way hath not been admitted (to my knowledge) 
amongst us ; nor have I often seen that a varicose ulcer could 
be cured by cutting off the branch leading to the ulcer, there 
being commonly more veins concerned in it." Wiseman's Chi- 
rurgical Treatises, octavo. Vol. I. page 325. 

* The following is the passage referred to in the preceding 
quotation : 

" In simple varix, according to the ancient practice, you are 
to proceed by section, dividing the skin, and separating the 
teguments ; and having raised the varicose vein, you are to pass 
a ligature above and another beneath it, making a delegation 
of them ; then slit the vein, cast out the gross blood, and af- 
terwards digest and heal it as is after said in an aneurisma .** 
Vol. I. page 108. 



A VARICOSE STATE OF THE LIMB. 237 

these dilated veins which disables the patient from 
bearing fatigue, this uneasiness being much increase 
ed by standing long, or walking. That these 
symptoms are peculiar to ulcers in this state of the 
limb is evident, for within a few hours after the 
vena saphena has been taken up, the symptoms dis- 
appear, and the patient is led to take notice of the 
distress it before gave him, and to express his sense 
of the suddenness of its removal. 

Another object is to prevent an increase of the 
dilatation of the veins of the limb ; which, when 
nothing is done to prevent it, are constantly grow- 
ing larger ; and after they have arrived at a certain 
size, become very painful on the smallest exertion, 
or continuing long in an erect posture, even where 
there is no ulcer. 

The mode of practice, which is now brought for- 
ward, had been followed for five years, when the 
first edition of this work was published ; and du- 
ring that period opportunities had occurred of see- 
ing its effects in twelve different instances. All the 
cases, except the first, were under my care in St. 
George's hospital, and many of the patients sub- 
mitted to this mode of treatment, from seeing the 
good effects of it upon others. Since that time my 



238 OF ULCERS ATTENDED WITH 

opportunities of seeing its effects, have been much 
increased. 

As every thing connected with the operative part 
of surgery carries along with it a certain degree of 
dread to the mind of the patient, any mode of treat- 
ment, however tedious, and even uncertain, is pre- 
ferred by many to an operation ; although the suf- 
ferings, when justly estimated, are too often ten 
times greater in obtaining a cure without such ope- 
ration, than with it. Under this prejudice, the ope- 
rations of surgery must continue while they are con- 
sidered abstractedly ; but when the diseases for the 
relief of which they are performed are taken into the 
account, and the pain and distress of the one is ba- 
lanced against the other, the prejudice will be re- 
moved ; and what, upon a superficial view, was con- 
sidered as cruel, will be found to be humane. The 
surgeon therefore, who discovers an operation by 
which a distressing disease is removed, should be 
viewed in the same light as any other benevolent 
man, who prevents or removes the sufferings of a 
number of his fellow creatures. 

The operation of taking up the vena saphena is 
extremely simple, may be performed in a very 
short time, and is attended with less pain, if we may 
judge from the account of those on whom it ha c 



A VARICOSE STATE OF THE LIMB. 239 

been performed, than it would be natural to expect. 
My attention has been directed in every case in 
which it has been performed, to render it as little 
painful as possidle, and the mode which appears to 
me the least so, is the following. 

As the veins are only turgid in the erect posture, 
the operation should be performed while the patient 
is standing ; and if placed on a table, upon which 
there is a chair, the back of the chair will serve him 
to rest upon, and he will have the knee joint at a 
very convenient height for the surgeon. The leg 
to be operated upon, must stand with the inner ankle 
facing the light, which will expose very advan- 
tageously the enlarged vena saphena, passing over 
the side of the knee joint. While the patient is in this 
posture, if a fold of the skin which is very loose at 
this part, is pinched up transversely, and kept in 
that position by the finger and thumb of the sur- 
geon on one side, and of an assistant on the other ; 
this fold may be divided by a pointed scalpel pushed 
through it with the back of the knife towards the 
limb, to prevent the vein being wounded ; much in 
the same way that the skin is divided in making an 
issue. This will expose the vein sufficiently, but 
there is commonly a thin membranous fascia, con- 
fining it in its situation ; and when that is met w T ith, 
the vein had better be laterally disengaged by the 



240 OF ULCERS ATTENDED WITH 

point of the knife. This is most expeditiously done 
by laying hold of the fascia with a pair of dissecting 
forceps, and dividing it ; for it is difficult to cut 
upon parts which give little resistance, and there b 
a risk of wounding the vein. After this, a silver 
crooked needle, with the point rounded off, will 
readily force its way through the cellular mem- 
brane connected with the vein, without any danger 
of wounding the vessel, and carry a ligature round 
it. This part, or indeed what may be considered 
the whole of the operation, being finished, the patient 
had better be put to bed, so as to allow the vein to 
be in its easiest state before the ligature is tied, and 
then a knot is to be made upon the vein ; this gives 
some pain, but it is by no means severe. The edges 
of the wound in the skin are now to be brought 
together by sticking plaster, except where the ligature 
passes out, and a compress and bandage applied, so 
as to keep up a moderate degree of pressure upon 
the vein, both above and below the part included, in 
the ligature. The inflammation, in general, is very 
trifling ; it does, however, in particular cases, extend 
for some way in the course of the veins under the 
the skin ; but even where this has happened in the 
greatest extent, it has been attended with no bad con- 
sequences. The ligature comes away about the 
ninth or not later than the twelfth day, after which 
the parts commonly heal up. 



A VARICOSE STATE OF THE LIMB. 241 

As it answers no good purpose for the ligature to 
remain so long, and only protracts the cure, I have 
been in the habit of removing it on the fifth day, 
which saves the patient five or six days of con- 
finement. The mode of removing the ligature is 
very simple ; the vein is so near the skin, that the 
knot is readily brought into view, and the ring of 
the ligature, which at the time of the operation was 
filled up by the vein, is now become loose, its con- 
tents having been considerably diminished by 
absorption, so that the point of a pair of scissors can 
be readily passed through it, by which it may with 
ease be divided, and the whole of the ligature 
brought away.. 

Cases occur in which there is a smaller vein 
running parallel to the vena saphena. This, when 
the vena saphena has been taken up, afterwards 
becomes enlarged, and continues the disease ; when 
that is the case, this vein also must be taken up. 
These circumstances ought to be attended to in 
the first examination of the disease, as sometimes 
the two veins are so close together, that they may 
both be included in the same ligature. 

This enlargement of the vena saphena is some- 
times combined with an enlargement of the branch- 
es of the vena saphena minor, or posterior, that 
passes up behind, between the two hamstrings ; 



242 OF ULCERS ATTENDED WITH 

when this is the case, the disease is in an uncom- 
mon degree of violence, and in such instances 
would be less likely to be attended with success, 
unless both venal trunks were taken up. 

In two or three cases there has been an enlarge- 
ment of the branches of the vena saphena minor, 
without the vena saphena itself being at all affect- 
ed ; the principal convolutions of the enlarged 
veins were on the calf of the leg, and on the out- 
side of the foot, just below the outer ankle. In 
these instances there was no ulcer, and therefore 
no very forcible reason could be urged to induce 
the patients to undergo an operation, nor was there 
the same chance of success, the use of a laced 
stocking was therefore recommended ; and in case 
that should not answer, it was explained to them, 
that they had it in their power afterwards to have 
recourse to taking up the venal trunk. 

The enlargement of the vena saphena minor, 
is rather mentioned as an uncommon occurrence, 
than as a case to be relieved by surgical treatment ; 
that when it is met with, it may be distinguished 
from the enlargement of the vena saphena, the 
subject under consideration. 

In one case where there was an ulcer, and only 
the branches of the vena saphena minor enlarged ; 



A VARICOSE STATE OF THE LIMB. 243 

the ulcer was situated more posteriorly than is 
usually met with, and the branches upon the calf 
of the leg were in an extremely varicose state, 
forming large projections, the trunk itself was 
very large, while the vena saphena was nearly of 
its natural size. The patient was a young woman 
of a very delicate constitution, but in good health j 
she was twenty-five years of age, and suffered so 
much pain in the ulcer, and in the course of the 
enlarged branches, as to be unable to walk or 
stand for any length of time, unless the limb was 
supported by bandage. 

As instances occur, in which, though the im- 
mediate branches of the vena saphena are affect- 
ed, the disease extends no farther ; and as the 
same thing happens, though less frequently, to 
the branches of the vena saphena minor ; and in 
other cases, the disease is found to take place in 
both, it becomes necessary to explain in what man- 
ner complicated cases may be distinguished. 

The branches of the veins, passing up from the 
foot to form these two venal trunks, anastomose 
very frequently and freely with each other ; it is 
therefore impossible to say precisely to which of 
them the collateral branches belong. 



244 OF ULCERS ATTENDED WITH 

When the vena saphena becomes enlarged, 
many of the common branches, and some of those 
belonging to the posterior trunk, will consequent- 
ly be affected ; and vice versa, when the vena sa- 
phena minor is enlarged. This, however, is not 
to be considered as implicating both veins in the 
disease, for the branches of one of them are 
only affected in a secondary way by their connec- 
tion with the other. Whatever number of the 
venal branches of the lower part of the limb is en- 
larged, if this enlargement in those of the upper 
part of the leg only extends in the course of one 
of the venal trunks, the disease should be refer- 
red to that trunk, whichever it is, as it is evident 
that the other, from its remaining of the natural 
size, can have had no part in the disease. 



A VARICOSE STATE OF THE MMB. 245 



CASES 

OF THE VENA SAPHENA INCLUDED IN A LIGA- 
TURE, TO PROMOTE THE CURE OF ULCERS ON 
THE LEG. 

AS this operation is a new one, so far as it is 
performed for the purpose of disposing ulcers to 
heal, the mode which appears to me the most un- 
exceptionable, of laying the facts ascertained re- 
specting it before the public, is giving a plain nar- 
rative of the several cases which have come under 
my care ; that they may become documents upon 
this subject. 



x2 



246 OF ULCERS ATTENDED WITH 



CASE I. 

A MAN, sixty years of age, had for many 
years gained his livelihood by going on messages, 
having been rendered unfit for more laborious 
employment by a large ulcer on the left leg, just 
above the inner ankle. The complaint was of 
twelve years standing ; it had been sometimes 
much better than at others, but had never been 
well during the whole of that period. 

In the year 1792, it became so bad as to confine 
him entirely. It was at this time I first saw him. 
Upon examining the limb, the veins were ex- 
tremely large and varicose, and the trunk of the 
vena saphena, at the knee, appeared almost the 
size of the litde finger. The size of this vein led 
me to the idea of taking it up at that part, witha 
view of relieving the lower branches from the 
pressure of the blood, which appeard to be the 
cause why the parts remained weak, and the ulcer 
could not be healed. My opinions upon this sub- 
ject were explained to the patient, and if he 
thought it worthy of trial, he was told of my rea- 
diness to do it for him. The man's desire to get 
well was such as to induce him to embrace the 



A VARICOSE STATB OF THE LIMB. 347 

offer of any mode of treatment which afforded 
the smallest chance of a cure. The vein was 
taken up in the way that has been mentioned. He 
complained of very little pain, no improper de- 
gree of inflammation was brought on by the ope- 
ration, the ligature came away in nine days, and 
in fourteen days the wound was healed. 

The ulcer upon the leg was dressed with dry 
lint ; it put on a better appearance on the second 
day after the operation ; on the fourteenth it had 
diminished in size one half, and in twenty-eight 
days was completely healed. He was also freed 
from a pain in the course of the veins of that leg, 
to which he had been subject for many years, 
whenever he used any exercise. 

He returned to his business of carrying mes- 
sages, and called upon me a year after, perfectly 
well ; his leg having continued sound. 



348 OF ULCERS ATTENDED WITH 



CASE H. 

Sarah Stapleton, a cook and housemaid, aged 
twenty-one years, in January 1794, was admitted 
a patient into St. George's hospital, on account of 
an ulcer upon her leg. The ulcer was situated 
upon the inside of the leg, a little above the inner 
ankle, had been of several months continuance, 
and was extremely painful, more particularly so 
at night, depriving her of rest. The pain was not 
confined to the ulcer, but seemed to run up in the 
course of the veins ; this was much increased 
after fatigue, or having been obliged to stand for 
any length of time, and consequently was great- 
est at night, after the labour of the day, which, 
from the nature of her situation, was very great. 

On examining the limb, the branches of the 
vena saphena were found to be much enlarged 
and varicose. Under these circumstances it was 
proposed to make a ligature upon the vena sa- 
phena. In performing the operation, which was 
done in the erect posture, she complained of great 
pain in the ulcer, from being obliged to stand 
firmly on that leg ; but as soon as the ligature was 
tied round the vein this pain ceased, and never 



A VARICOSE STATE OF THE LIMB. 249 

afterwards returned. In the time of the opera- 
tion a smaller vein was observed running parallel 
to the vena saphena, which afforded a reasonable 
suspicion that the disease might recur : as, how- 
ever, this was uncertain, the circumstance was 
only mentioned, and it was left to herself to deter- 
mine whether she would have it taken up at that 
time, or take the chance of its enlarging, and 
whenever it did so, have a repetition of the opera- 
tion. She preferred the last. The ligature came 
away in ten days, the ulcer on the leg healed up 
entirely in three weeks, and she was discharged 
from the hospital perfectly well. 

She went again to service, in the capacity of 
cook, in a small family ; and from the nature of her 
business was much exposed to the fire, and obliged 
to stand a great deal, which made the veins of that 
leg swell and increase in size ; but the leg con- 
tinued sound, and she had no return of the pain. 
Fifteen months after the vena saphena had been 
tied, a vein in the place where the ulcer had for- 
merly been situated burst, and bled freely ; it stop- 
ped, however, of itself; the quantity of blood 
w r hich was lost alarmed her considerably, and 
made her return to the hospital for advice. 

Upon examining the vena saphena, at the part 
where the ligature had been applied, two very 



250 OF ULCERS ATTENDED WITH 

large veins were discovered ; so that there must 
have been, at the time of the operation, two small 
branches, one on each side of the vena saphena ; 
one of these only had been observed at the form- 
er examination. These two veins were now in- 
cluded in one ligature. This was done April 17, 
1795. Tying the veins gave considerable pain, 
which did not entirely go off for two days, and 
then subsided ; on the 22d, the ligature was re- 
moved, after which the parts were much easier, 
and in a week the wound healed up. 

The ligatures which are applied to secure ves- 
sels in all operations, while they remain in the 
wound, act as extraneous bodies, and keep up a 
degree of irritation, which, although it differs in 
almost every two patents, is generally considera- 
ble : this is known by the relief the patient expe- 
riences after their removal. The leg for a time 
gave the feel of weakness, and swelled when walked 
upon for a number of hours ; but this gradually 
went off, and by the beginning of May, she left 
the hospital. 

The swelling of the leg for a few weeks after 
the operation, is a symptom which occurred in 
«^eral instances. 



A VARICOSE STATE OF THE LIMB. 251 



CASE III. 

A man, sixty years of age, in the year 1794, 
was admitted into St. George's hospital, on ac- 
count of an ulcer upon his leg, of many years 
standing. It proved to be one of those attended 
with large and varicose veins ; the connection be- 
tween the two complaints was explained to him, 
and it was proposed to take up the vena saphena, 
which he readily consented to have done. In 
this case the vein was strong in its coats, and 
rolled more loosely in the cellular membrane than 
it had been found to do in younger patients. It 
was readily included in a ligature. The ulcer, 
immediately after the operation, put on a more 
kindly appearance ; it healed more slowly than in 
the two former cases. This probably arose from 
the man's age ; but in a month's time it was per- 
fectly well. It is to be remarked, that no dress- 
ings were made use of, in this or any of the 
other cases, but dry lint and white ointment, un- 
less they are particularly mentioned. 



252 OF ULCERS ATTENDED WITH 



CASE IV. 

Richard Pinkley, thirty-four years old, had 
complained of a swelling of one of hisdegs for ten 
years, during the latter part of which period, the 
veins had gradually enlarged, and an ulcer had 
broke out a little above the inner ankle, which 
healed up* but broke out again. This happened 
several times ; and at last the ulcer became so 
large and painful as not to admit of being healed, 
which induced him to become a patient in St. 
George's hospital. He was admitted under my 
care, and the operation of taking up the vena 
saphena was proposed as the only means of making 
the leg continue sound. To this he readily acce- 
ded. The operation was performed on the 10th 
of April, 1795. The vein was very large, and on 
the third day a swelling came upon the leg ; on the 
sixth the ligature was removed, the inflammation 
increased, and extended itself in the course of the 
venal branches. It was evidently of the erysipe- 
latous kind ; it also spread up the thigh, and the 
ulcer put on a foul appearance ; on the tenth, the 
inflammation began to subside ; on the twelfth it 
was still more diminished, but the swelling re- 



A VARICOSE STATE OF THE LIMB. 253 

mained the same ; the ulcer now put on a better 
appearance. On the eighteenth the inflammation 
was very much gone off ; and by the twenty- 
eighth day, from the operation, the man was per- 
fectly well. 

The erysipelatous inflammation which attacked 
the leg and thigh is to be considered, in some mea- 
sure, as accidental, and not connected with this 
particular operation ; it is very frequently met 
with in all hospitals, and in the spring of the year 
we find, at St. George's hospital, that a great num- 
ber of the surgical patients are liable to it, whether 
their complaints arise from accident, operation, or 
ulcers of long standing. It appears to be occa- 
sioned by some peculiarity in the state of the air 
at that season of the year ; and when the erysipe- 
latous inflammation had once begun, the irritation 
from the ligature would direct it along the course 
of the vein. 



254 OF ULCERS ATTENDED WITH 



CASE V. 



A man, sixty years of age, whose business was 
that of an out-door porter to a banking house, in 
June, 1794, came into St. George's hospital with an 
ulcer upon the inner side of the right leg, of several 
years standing. This ulcer had been repeatedly 
healed, but always broke out again ; and, at the 
time when he came into the hospital, rendered him 
unfit to bear the fatigue of his business. The veins 
of the limb were much enlarged, and consequently 
extremely varicose. It was proposed to tie the 
vena saphena, to which he assented. The operation 
was attended with little pain, and the ligature came 
away the ninth day after the operation, and on the 
fourteenth the wound was entirely healed. The 
hospital now disagreed with his general health ; 
this he attributed to the confinement, and the want 
of his usual exercise, having been accustomed to be 
much in the open air. He lost his appetite ; and 
the ulcer on the leg spread to a considerable size. 
Under these circumstances he was moved into pri- 



A VARICOSE STATE OF THE LIMB. 255 

vate lodgings. As soon as he left the hospital he 
began to recover, and, in less than six weeks from 
the time of the operation, the ulcer on the leg was 
entirely healed, and he was discharged cured. 



256 OF ULCERS ATTENDED WITH 



CASE VI. 



Anthony Kennedy, a footman, aged thirty-five, 
in the year 1793, about the month of April, found 
that the veins of his left leg had become unusually 
large ; they continued to increase in size, and in six 
months an ulcer broke out just above the inner an- 
kle. This ulcer spread, and in eight weeks was so 
large and painful, that he was obliged to leave his 
place, and go into the infirmary at Dumfries, where 
he continued five months ; during which time his 
leg got quite well. He returned to his master, and 
went with him to Bath, where the ulcer broke out 
again. The veins of the right leg began to enlarge 
in the same way, and an ulcer broke out upon the 
same part of that leg. For these two ulcers he was 
under the care of several surgeons of eminence in 
Bath for five months, without receiving benefit : he 
then went into the Bath infirmary, and was there 
six months, and both the ulcers got well ; but in 
two months time they both broke out again, and 
were more painful than they had ever been before. 
He was now received into the Bristol infirmary, 



A VARICOSE STATE OF THE LIMB. 257 

and continued there six months ; the ulcers, how- 
ever, could not be again healed ; and he was told 
by the surgeons, that their not being able to heal 
them was of no consequence, as they would break 
out again ; and therefore he could not have a per- 
manent cure. Under these circumstances he came 
to London, and applied to me for assistance ; by my 
advice he became a patient in St. George's hospital, 
where he was received on the 5th of February 1796. 

At this time there was an ulcer on each leg, 
which had a foul appearance ; the branches of the 
vena saphena of both legs were very much enlarged 
and varicose. It was explained to him that the ul- 
cers were prevented from healing by this enlarge- 
ment of the veins ; and it was proposed to take up 
the vena saphena of each leg, assigning the reasons, 
and describing the advantages which might be ex- 
pected. He very readily consented to have any 
thing done which was thought necessary ; and on 
the 9th of February the vena saphena of the left leg 
was taken up. On the 16th the ligature was re- 
moved, the wound had a very healthy appearance, 
and the ulcer was evidently better. On the 19th, 
the vein of the right leg was treated in the same 
way, and the ligature was removed on the 23d. He 
felt very little pain in either limb during the opera- 
Y 2 



^5B OF ULCERS ATTENDED WITH 

tion, and had none afterwards. The ulcers, td 
which the only applications were dry lint and simple 
ointment, made a very rapid progress towards 
healing. On the first of March, the wound made 
in the first operation was healed, and on the eighth, 
that made by the second had also healed. On the 
26th, the ulcer on the left leg was skinned over, 
and that on the right leg nearly so ; this last, how- 
ever, was a fortnight longer before it healed. 
About the 14th of April he was discharged from 
the hospital. 



A VARICOSE STATE OF THE LIM3. 259 



CASE VII. 



Robert Bradbury, nineteen years of age, a gentle- 
man's servant, was admitted into St. George's hos- 
pital June 23d, 1796, with an ulcer upon his left leg. 
The following is the history of the case. The veins 
of that leg had been enlarged for many years, but 
he had felt no great uneasiness from this circum- 
stance till a year and a half before ; when, in con- 
sequence of a kick upon that leg, just above the 
inner ankle, an ulcer took place, which healed and 
broke out again. This happened several times, and 
at every return it put on a worse appearance, and 
was longer in healing ; and, at the time when he 
came to the hospital, it was not at all disposed to 
heal. 

Under these circumstances the state of the veins 
was considered as the cause of the ulcer remaining 
in an indolent and unhealthy state, and it was pro- 
posed to take up the vena saphena, as a means of 
producing a permanent cure. On the 26th of June 
the operation was performed, on the 30th the liga- 
ture was removed. On the 4th of July the veins 



260 of ulcers attiv::; 

were evidently diminished in size, and the ulcer an 
the leg was entirely healed. On the 8th the wound 
made in taking up die vein was so nearly well as to 

7 •::' u: : :ns eiuer.ee. and he was allowed to leave 
the hospital, and return to his master. 

Five months after there had been no return of 
the ulcer. 



A VARICOSE STATE OF THE LIMB. 261 



CASE VIII. 



James Peasnell, a footman, twenty-eight years of 
age, had an ulcer on the inner ankle of the left leg, 
for twelve weeks, with a varicose state of the branch- 
es of the vena saphena of that leg. This he attribut- 
ed to the cramp, and thinks that the veins began to 
increase sixteen years ago. This enlargement of 
the veins had given him no pain, unless they were 
much pressed, or when he was carrying a heavy 
burthen. He was admitted into St. George's hos- 
pital, under my care, on the 9th of October, 1796, 
for the purpose of having the vena saphena taken up 
by ligature, with a view of making the ulcer heal, 
and relieving the uneasy symptoms produced by the 
enlarged state of the veins. 

He had been a patient in the hospital a month be- 
fore, but no mode that was adopted succeeded in 
disposing the ulcer to heal, whichs. induced him to 
apply for this mode of procuring relief. On the 10th 
of October the operation was performed; on the 



262 OF ULCERS ATTENDED WITH 

14th, when the veins were pressed by the finger, 
they did not give the same pain he had formerly felt, 
and the ulcer on the ankle had a better appearance. 
On the seventh day the ligature was removed, and 
the wound superficially dressed. On the ninth day 
he had an attack of fever ; on the tenth was rather 
better : but an erysipelatous inflammation came upon 
the wound, and extended down the leg, in the course 
of the cellular membrane : but the branches of 
the vena saphena were not affected by it. On the 
fifteenth there was an abcess formed in the calf of 
the leg ; he was still very much indisposed in his 
general health ; on the nineteenth a second ab- 
scess formed, a little below the other, and the two 
openings communicated with one another, the cel- 
lular membrane under the skin having been de- 
stroyed. 

From this time he became daily worse ; on the 
thirtieth day he had a cough, loss of appetite, and 
hectic fever. As it was conceived these symptoms 
arose from the air of the hospital disagreeing with 
him, it was proposed he should be immediately re- 
moved into private lodgings, but from several cir- 
cumstances this was not done till the fortieth day. 
He was no sooner out of the air of the hospital 
than he was able to sleep, and recovered his appe- 



A VARICOSE STATE OF THE LIMB. 263 

tite ; and in three weeks time his general health 
was re-established, all the ulcers formed by the dif- 
ferent abscesses were healed, and he returned to his 
master. 



264 OF ULCERS ATTENDED WITH 



CASE IX. 



John Baker, a labourer, aged sixty-two, twenty 
years ago, by accident, cut one of the branches of 
the vena saphena with a bill ; the wound very soon 
healed, but the branches of the vein became enlarged 
and varicose, and have occasionally been painful 
ever since, when pressed. 

In August, 1 796, he received a hurt on his inner 
ankle, which formed an ulcer ; he went on for two 
months making use of different applications, but at 
the end of that time it became so large and painful, 
that he was induced to apply for relief at St. 
George's hospital. He was admitted on the 8th of 
October. Upon its being explained to him that 
the ulcer was prevented from healing by the enlarge- 
ment of the veins of the leg, he readily submitted 
to any operation which would facilitate the cure of 
the ulcer. 

On the 10th the vena saphena was taken up ; soon 
after this operation, the pain which he had felt in the 
vein, when pressed, gradually became less, and the 



A VARICOSE STATE OF THE LIMB. 265 

ulcer had diminished in size. The only dressing 
employed was dry lint. On the seventh day after 
the operation, the ligature was removed, and the 
wound looked very well ; it continued healing for 
several days, after which it inflamed and spread, 
the ulcer on the ankle taking on the same disposi- 
tion. Under the use of the carrot poultice this in- 
flammation subsided, and the parts again put on a 
healing appearance. At the end of five weeks the 
man was discharged, the wound made in taking ,up 
the vein being completely healed, and the ulcer on 
the ankle so very small, that he could not be induced 
to remain longer in the hospital. 

In these cases the vena saphena was taken up on 
account of ulcers on the leg, proving so obstinate un- 
der every mode of treatment which could be devis- 
ed, that the patients readily submitted to the opera- 
tion, with a view to have them healed. 

In all ..of them, the ulcers put on a much more 
healthy appearance, in less than three days after the 
operation ; and from that time, where no circum- 
stance occurred to prevent it, went on healing like 
ulcers in healthy parts. 

The veins of the limb in all of them became evi- 
dently smaller next day, in some of the cases in a 



* 



266 OF ULCERS ATTENDED WITH 

very remarkable degree ; and in the course of a 
week they were in general very much diminished in 

size* 

In those cases that were attended with fever, in- 
flammation, and general loss of health, alljjiese ef- 
fects were combined in the same case, and so very 
similar to what occurs in hospitals, from change of 
mode of life, and a more confined situation than the 
patient has been accustomed to, that they are partly 
to be attributed to these circumstances, and might 
have taken place, if no operation had been perform- 
ed. It is natural at the same time to suppose, that, 
in irritable habits, applying a ligature round a large 
vein may so far affect the general system, as to dis- 
pose the body to be more readily affected by such 
causes. 

That it may not appear that too much stress has 
been laid upon the effects which confinement and the 
air of an hospital have upon the constitution of many 
individuals, particularly after having undergone an 
operation, the following remarks are stated on that 
subject. 

The injury the constitution receives from long 
confinement in an hospital is sufficiently understood ; 
but that it can suffer in so short a period as a week, 



A VARICOSE STATE OF THE LIMB. 267 

or a fortnight, will not be so readily believed, al- 
though instances of this kind are not unfrequently 
observed in practice. Were these effects confined 
solely to hospitals, they might be attributed alto- 
gether to bad air, much to the discredit of those 
charitable institutions ; but this is by no means the 
case, as the same thing happens to private pa- 
tients. 

In three different instances of young women, who 
came out of the country to have operations per- 
formed in London, their; health began to fall off at 
the end of the fortnight, and continued to decline 
till they were carried out into the air ; and from the 
time of taking the first airing there was so evident 
an amendment, as to show that air alone was suffici- 
ent to bring about a recovery, which very soon took 
place, by daily going out in a carriage. Their lodg- 
ings were in the neighbourhood of Leicester-square, 
which cannot be considered as a very confined situa- 
tion. After getting well, their general health did 
not suffer from remaining some weeks in the same 
lodgings ; so that London could not be said to 
disagree with them. In conversations upon this 
subject with two of these patients, they mentioned, 
that they never could bear being confined to their 
room, even for a few days, without suffering from it 



268 OF ULCERS ATTENDED WITH 

If this ever happens in private practice, it must 
very frequently occur in all hospitals, even the most 
airy, both from the construction of the wards, and 
the situation of the buildings. Gardeners, farmers, 
and persons of that description, are soonest affected 
by it ; and many instances have occurred of their 
losing their health in less than a fortnight in St. 
George's hospital, and getting well in a few days 
after being more in the air. 

The foregoing cases were the only ones which I 
had met with at the time the first edition of this work 
was published, and they are now reprinted, with the 
same remarks annexed to them as in that edition. 

Since that time, a great many similar cases have 
come under my observation ; from these it is evident 
that the fever and inflammation, which occasionally 
take place, are direct consequences of the operation, 
and arise from the inflammation extending itself 
along the vein, sometimes in both directions, but 
more commonly towards the foot. 

This being ascertained, it naturally leads me to 
point out in what manner these consequences may 
be obviated ; this may be readily done by including 
the vein in two ligatures, distant about half an inch 
from each other, and cutting the vein across in the 



A VARICOSE STATE OF THE LIMB. 269 

intermediate space ; by this means the two ends of 
the divided vein are allowed to contract, and the 
inflammation does not extend itself beyond the li- 
gatures. 

If such inflammation was a constant attendant 
upon the operation of tying the vein in the more 
simple manner, this conipound operation should un- 
doubtedly be always preferred ; but as it only hap- 
pens occasionally, and is ultimately productive of 
benefit to the patient, by obliterating a greater extent 
of the vein, and making him less liable to a recur- 
rence of the disease, it becomes a question, whether 
there are not more circumstances in favour of the 
one than the other. 

There are cases, in which exposing the vein for 
half an inch in extent would be a very difficult and 
severe operation ; and there are others, in which it 
may be done with the greatest ease ; there are con- 
stitutions, which would lead the surgeon to expect 
great irritability in the venal system ; others, in 
which there are no grounds for such a supposition ; 
it must therefore be left to the judgment of the sur- 
geon to decide which mode is best adapted to the 
individual cases under his care ; but when the trunk 
of the vein at the part where it is to be taken up is 
z 2 



270 OF ULCERS ATTENDED WITH 

unusually large, and there are dilatations forming 
pouches immediately above and below that part, the 
vein should be always taken up by two ligatures, 
and divided in the intermediate space. 



While this sheet was in the press, my friend Dr. 
Baillie informed me that Ambrose Parey had not 
only proposed the same operation, but performed it 
in exactly the same way. This author I had not 
before consulted, taking it for granted that Wise- 
man, who has professedly given the opinions of the 
ancients, had stated every thing material from their 
works. 

Upon consulting Parey, I find the state of the 
veins just mentioned is that in which he recommends 
the operation; although the principle on which it- 
was proposed is erroneous, he has undoubtedly the 
merit of pointing out the most simple mode of doing- 
it, as well as of stating the advantages the ulcer on 
the lower part of the leg derives from the operation. 

Had I been acquainted with his observations, I 
should certainly in the former edition have done 



A VARICOSE STATE OF THE LIMB, 271 

him that justice which is due to him, and which I 
now do, by inserting his remarks in the annexed 
note. # 

* A varix is therefore cut or taken away, to intercept the pas- 
sage of the blood flowing to an ulcer seated beneath, or else, 
lest that by the too g-reat quantity of blood the vessel should 
be broken, and death be occasioned by a hemorrhagic proceed- 
ing from thence. Now this is the manner of cutting it : let the 
patient lie upon his back on a bench or table, then make a li- 
gature upon the leg in two places, the distance of some four 
fingers each from other, wherein the excision may be made, for 
so the vein will swell up and come more in sight, and besides 
you may also mark it with ink ; then taking the skin up between 
your fingers, cut it longways, according as you have marked it ; 
then free the bared vein from the adjacent bodies, and put 
thereunder, a blunt pointed needle (lest you prick the vein) 
thred with a long double thread, and so bind it fast ; and then 
let it be opened with a lancet in the middle under the ligature, 
just as you open a vein, and draw as much therehence as shall 
be fit : then straight make a ligature in the lower part of the 
forementioned vein, and then cut away as much of the said 
vein as is convenient between the ligatures, and so let the ends 
withdraw themselves into the flesh above and below ; let these 
ligatures alone until such time as they fall away of themselves. 
The operation being performed, let an astringent medicine be 
applied to the wound and the neighbouring parts, neither must 
you stir the wound any more for the space of three days." A. 
Parey's Works, translated by Johnson, folio edition, page 319. 



CHAPTER X. 

THE EFFECTS OF LIGATURES ON VARICOSE VEINS 
IN CASES OF ENLARGED VENA SAPHENA, VARI- 
COCELE, AND PILES. 

JL he diseases which are considered in the present 
chapter do not belong tc* the general subject of the 
work, having no connection whatever with ulcers ; 
but as the treatment which is proposed was first 
suggested by attending to the effects of a varicose 
state of the veins upon ulcers, and the advantage 
derived to the ulcer from the trunk of the vein being 
included in a ligature ; it must be allowed that the 
following observations throw additional light on the 
beneficial effects of that operation. 



THE EFFECTS OF LIGATURES, &C. 273 



©N TYING THE VENA SAPHENA, TO RENDER IT 
LESS VARICOSE. 



From the eases stated in the last chapter, it is 
evident that the branches of the vena saphena be- 
come diminished in size after the operation of tying 
the trunk, but this might be partly attributed to the 
effect of the operation upon the ulcer ; for improv- 
ing the state of the ulcer would naturally remove a 
considerable degree of irritation from the veins of 
the leg. 

That it does not depend upon that cause will be 
sufficiently proved by the following cases. 

It is proper to remark that the only cases of this 
disease, in which great benefit is to be expected, are 
those in which the enlargement belongs to the bran- 
ches of the vena saphena, major or anterior ; for 
where all the smaller branches upon the foot and leg 
are universally affected, the disease is too general 
to admit of relief from any one trunk being taken 
up. 



274* THE EFFECTS OF LIGATURES 

When the branches of the posterior vena saphena 
are enlarged, it would be natural to expect the same 
degree of advantage from taking up the trunk in 
the ham, but that does not happen ; this vein has 
been taken up in several instances, but in none of 
them was the benefit sufficient to encourage a re- 
petition of the operation in similar cases. 



ON VARICOSE veins; 275 



CASE I. 



A. B. thirty-five years of age, a house-painter 
by trade, came to St. George's hospital, in the year 
1T94, to have advice for a weakness in his limbs, 
that rendered him unfit to follow his business, 
which required him to stand a great deal. Upon 
examining his legs, the veins were extremely large 
and varicose, equally so on both of them ; there 
was no local disease of any kind, only pain and 
inability to stand long at a time. He was probably 
rendered more liable to this disease by the debili- 
tating effects of lead. 

From the success met with in the cases above re- 
lated, it was thought he might receive material be- : 
nefiMrom having the vena saphena taken up, it was 
therefore proposed to him that it should be tried in 
one leg; and if he found sufficient advantage from it, 
he could have it done on the other. To this he readily 
assented, and the operation was performed. In this 
case there was a considerable vein close to the vena 
saphejia, which was included in the same ligature ; 
the operation gave little pain, and was not followed 



276 THE EFFECTS OF LIGATURES 

by any uneasiness : the ligature came away on the 
ninth day, but the wound did not heal ; he became 
faint and languid, had tremblings and cold sweats, 
with loss of appetite. These symptoms came on 
after being a fortnight in the house, and appeared to 
arise, in some measure, from the air of the hospi- 
tal disagreeing with him ; that this was partly the 
cause, was confirmed by their being much relieved 
by getting him to walk out every day in the air, 
and by the internal use of Peruvian bark. As soon 
as he recovered, which was in about a month, he 
was advised to go into the country, and re-establish 
his general health, for the confinement in an hospi- 
tal disagreed too much with his constitution, to ad- 
mit of any thing being done at that time to the other 
leg ; and at some future period he might return, if 
the result of the operation encouraged him to have 
it repeated. No opportunity has occured of seeing 
him since that time, so that no conclusions can be 
drawn from this case, beyond the immediate effects 
of the operation, which were favourable, the veins 
of the limb being rendered much smaller than they 
were before. 



ON VARICOSE VEINS. 277 



CASE II. 



Thomas Gough, aged forty, came to St. George's 
hospital, and was admitted under my care, on ac- 
count of weakness and swelling in the right leg, 
which prevented him from engaging in any employ- 
ment of fatigue ; there was no ulcer upon the leg, 
but a constant degree of uneasiness, which was 
always increased by standing or walking. Un exa- 
mining the leg, the veins were much enlarged and 
varicose, and, what is unusual, there were two 
venal trunks passing up the thigh, one the vena 
saphena, the other a branch of nearly the same 
size, at some distance from it. It was proposed 
that both of them should be taken up : as, however, 
they were too much apart to be included in one 
operation, and too near to admit of both being ta- 
ken up at the same time, without the inflammation 
extending over the intermediate space, it was deter- 
mined to take them up separately, allowing the in- 
flammation from the first operation to go off before 
the second was attempted. On Jt$y the 22d the 
a a 



278 THE EFFECTS OF LIGATURES 

vena saphena was taken up : on the 26th the liga- 
ture was removed, and the wound had a very fa- 
vourable appearance ; on the 29th the collateral 
branch was taken up ; and on August the 2d the 
ligature was removed. The leg was less swelled, 
and entirely free from pain, the veins appeared to 
be contracted in their size, and on the 5th he went 
into the country, one of the woun^ ^eing entirely 
healed, and the other nearly so. 



ON VARICOSE VEINS. 279 



CASE III. 



John Mathews, aged twenty-six, a gentleman's 
servant, can^ into St. George's hospital on the 1 9th 
of April, 1 # , on account of a varicose state of the 
veins of the right leg. He perceived, about ten 
years before, that the veins of the leg were larger 
than those of the other, and whenever he stood or 
sat long in the same posture, they swelled and be- 
came painful. Three years ago he received a cut 
upon the inner ankle, which divided a branch of the 
vena saphena ; it bled profusely, and the hemorrhage 
returned several different times. Two years after 
that he bruised the same leg against a cartwheel, and 
hurt i t so much as to be confined to his bed for 
seven weeks with a large ulcer, situated upon the 
inner side of the leg, a little above the ankle-joint ; 
this ulcer healed under the use of a tight bandage, 
applied, to the whole limb, from the toes to the 
knee. 

The varicose state of the veins was now T his only 
complaint, and it was so troublesome, as to induce 
him to come into the hospital, for the express pur 



280 THE EFFECTS OF LIGATURES 

pose of having the trunk of the vena saphena taken 
up, to relieve the branches situated upon the leg 
from the pressure of the column of blood, by which 
the dilatation was continuing to increase. 

Upon examining the limb, the dilatation seemed 
to be confined to those branches which form the 
vena saphena ; but the trunk of this vein was deeper 
seated than common ; it did not lie loose under the 
skin, but imbedded in the fat and cellular mem- 
brane ; this was so much the case, that it became 
necessary to make compression upon the thigh, to 
render the vein more prominent. After dividing 
the skin, the vein was not exposed clearly to view, 
but it was now very distinctly felt. Under these 
circumstances I applied the forefinger of the left 
hand upon the vein, as a guide to the knife, and 
detached the fat and cellular membrane on one side 
with the point, so as to make room for the blunt 
needle to get readily behind the vein : in this way 
the ligature was passed round it, and tied in the 
same manner, as has been mentioned in the other 
cases. The operation was performed on the 22d 
of April ; on the 25th, which was the third day, 
upon removing the dressings and sticking plaster, 
there was an erysipelatous inflammation, extending 
a little way up the thigh and down the leg, in the 
course of the veins ; this induced me to cut out 



ON VARICOSE VEINS, 281 

the ligature, from the idea that this inflammation 
was brought on by it. He felt immediately easier ; 
on the fourth day the inflammation was much 
abated, and on the fifth it was quite gone off. He 
now mentioned that the pain he had been accustom- 
ed to feel in the veins of his leg was gone away. 
On the sixth day the wound was reduced to a small 
superficial ulcer, which healed up in a few days. 



Ad 2 



282 THE EFEECTS OF LIGATURES 



ON TYING THE SPERMATIC VEIN IN CASES OF 
VARICOCELE. 

Cases of varicocele are by no means uncommon, 
but they rarely increase to so great a size, as to 
lead the patient to the idea of having any operation 
performed for their relief. 

They almost always happen in the left testicle 
and spermatic chord, in consequence of the returning 
blood from that testicle having a circuitous route to 
the vena cava ; the spermatic vein terminating most 
commonly in the left emulgent vein, and when it 
does so, the angle at which they unite is nearly a 
right angle 

From the following case it appears, that in some 
instances this disease becomes so distressing as to 
make the patient seek relief at any hazard, and the 
symptoms that occurred were such as would lead 
me, in any future operation of the same kind, to 
take up the vein in two places, and divide the 
intermediate portion, with a view to make the in- 
flammation less liable to run along the vein, and 
consequently render the pain less severe. 



ON VARICOSE VEINS. 283 



CASE. 



George York, aged twenty-eight, a tailor by trade 5 
in the year 1788, while, in North America, had a hy- 
drocele, which was cured by means of a seton passed 
through the sac of the tunica vaginalis. It was 
three months before he recovered from the effects of 
the operation ; and three months after he got well, 
the testicles seemed to enlarge, and the scrotum be- 
came very uneasy when pressed. He came to Eng- 
land in the year 1795, and applied to several sur-» 
geons for relief, the scrotum being at that time so 
large, and the testicles so uneasy, that he could not 
follow his usual occupations. He was directed to 
live low, and take internal medicines of a cooling 
and purgative nature ; to apply the solution of sal 
ammoniac to the part, and to keep it suspended. He 
followed this plan for some weeks ; but, receiving- 
no benefit, relinquished it. 

His complaints preventing him from pursuing the 
on>v mode of life by which he could get a livelihood, 
wnich was going to sea as a ship-tailor, he was very 



284 THE EFFECTS OF LIGATURES 

desirous of having something done for his recovery* 
He came to St. George's hospital, and consulted me 
how far any operation could be performed for his 
relief, as he was willing to submit to the loss of the 
testicle, rather than continue in his present state. 

Upon examining the parts, the scrotum was found 
to be unusually thickened, and the veins of the left 
testicle to be so much enlarged, as to increase its 
bulk beyond what is considered as a large hydrocele. 
The veins were all convoluted, and moved readily 
on one another, and appeared to be the only cause 
of this increased size of the testicle. On the tes- 
ticle of the right side there was an incipient hydro- 
cele, containing about two ounces of water. 

In this state of the left testicle little was to be ex- 
pected from internal medicines, and the removal of 
it appeared to be a cruel operation. The patient 
could not be prevailed upon longer to go on with 
his complaint in its present state. He had be- 
fore been told that the disease was an enlargement 
of the veins ; and had seen two patients of mine in 
the hospital, who had received considerable benefit 
in cases of varicose veins of the leg, by having the 
vena saphena taken up at the knee, and wanted to 
know if a similar operation could not be performed 
upon the veins of his testick. The only answer 



ON VARICOSE VEINS. 285 

made to this question was, that I would not propose 
to him any such operation, having no knowledge of 
its effects ; at the same time believed there was so 
little danger in it, that if he chose to have it perform- 
ed, I had no objection to comply with his desire, 
although I did not feel myself authorised to take it 
entirely upon myself. I begged he would not at 
that time come to any resolution, but turn it in his 
mind before he came to a determination. 

He returned to the hospital some days after, and 
said he was resolved to have the veins taken up ; 
and the operation was performed on the 15th of 
March, 1796, in the following manner: I en- 
deavoured to find the spermatic chord, and having 
done so, grasped it between my finger and thumb, 
and pushed forwards the surrounding veins, so as to 
make them press against the external skin of the scro- 
tum : while the left hand was thus engaged, I di- 
vided the skin, without wounding the veins ; and 
the moment the incision was made, several convo- 
lutions were protruded between the lips of the 
wound, covered by a strong tendinous fascia, which 
confined them in their situation ; when that was 
cut through, they projected beyond the aperture ; 
it was necessary to divide this fascia a little more 
freely, to get readily behind this vein, which by its 
convolutions on itself formed a thick plexus. A 



286 THE EFFECTS OF LIGATURES 

needle, the point of which had been rounded off, 
was then passed behind the convoluted vein, and 
inclosed it in a ligature. 

The moment the ligature round the vein was 
drawn tight, a cold sweat came on, and he fainted 
away : in a few minutes he recovered, and was to- 
lerably well. For the first three days nothing par- 
ticular occurred, the wound had no unusual appear- 
ance. On the fourth day his tongue became white 
and dry, his pulse small and low, the beat not ex- 
ceeding fifty in a minute ; these symptoms coming 
on unaccompanied with any change of the local ap- 
pearances, led to the belief that they were not the 
effects of the operation, but the symptoms of a com- 
mon fever ; and this was strongly corroborated by 
the circumstance of there being two or three patients 
in the hospital attacked in a similar way, indepen- 
dent of local injury. On the fifth the parts were 
very tender and uneasy, and put on a sphacelated 
appearance, but the fever had abated. Eighth day 
the ligature came away, and he was n^v so free 
from the fever as to take the bark. The abatement 
of fever and irritation immediately after the coming 
away of the ligature, is sufficient proof that they 
were brought on and kept up by the presence of the 
ligature. Twelfth day, the wound became very 
irritable, and could not bear the dressing ; the 



ON VARICOSE VEINS. 287 

parts were therefore fomented every hour. He 
took thirty drops of aether and tincture of opium, 
as often as was found necessary to take off the pain, 
which was very acute. On the sixteenth the sloughs 
were entirely separated from the wound, and it put 
on a healthy appearance ; and on the twenty-fourth 
day it became a superficial ulcer : and by the twen- 
ty-sixth was perfectly well. At the time the wound 
healed, the testicle and its vessels were diminished 
to one half of the size they had acquired before the 
operation. 

He was kept in the hospital, and had the opera- 
tion for the radical cure performed on the hydrocele 
of the tunica vaginalis of the other testicle. This 
was done by an injection of equal parts of wine and 
water, and succeeded perfectly. He then left the 
hospital, having continued there a month after he 
had got well of the operation for the varicose veins ; 
the parts remained in the same diminished state, 
not being at all affected by the operation for the hy- 
drocele, although so near them. 

On the 30th of November he returned to the hos- 
pital,' with a view, he said, to have the testicle still 
more reduced, by having another vein taken up. 
From this I endeavoured to dissuade him, by point- 
ing out the violence of the former symptoms ; but 



288 THE EFFECTS OF LIGATURES 

the benefit he had received from the first operation 
had so strongly impressed him with a belief that 
another operation would complete the cure, that all 
the arguments urged in favour of his being satisfied 
with his present state were in vain. Finding he 
would be unhappy unless something more was done, 
and there being no apparent danger in taking up a 
large vein, which lay very superficially on the an- 
terior part of the spermatic chord, no further objec- 
tion was made to his wishes, and he was taken into 
the hospital for that purpose. 

On the 2d of December this vein was taken up 
while the patient was in an erect posture, exactly in 
the manner described in the cases of the vena saphe- 
na. As soon as the ligature was passed behind the 
vein, the man fainted, but recovered uponbeinglaid 
in an horizontal position. 

As the immediate symptoms in the last operation 
had been very severe, with a view to make them 
less so in the present, the vein was not immediately 
tied, but left till the next day with a loose knot upon 
it ; he had an opiate given him, but had no sleep 
in the night ; he was however tolerably free from 
pain. Next day the ligature was tied as tight as the 
parts could bear. This did not produce any pain 
or distressing symptoms. On the fifth day from 



ON VARICOSE VEINS. 289 

the operation the ligature was removed, by dividing 
the noose with a pair of scissors, and the wound was 
treated as a superficial ulcer. The general bulk of 
the testicle was become much smaller, and the parts 
free from any degree of inflammation. On the 
thirteenth, on account of some very indecent con- 
duct, he was discharged from the hospital by order 
of the Board, the wound being nearly healed. 

I have since heard that he imprudently exposed 
himself in the very severe weather about Christmas, 
caught a violent cold, which fell upon his bowels, and 
carried him off. 



Bb 



290 THE EFFECTS OF LIGATURES 



ON TYING PILES SO AS TO PREVENT THE PAINFUL 
SYMPTOMS USUALLY PRODUCED BY THAT OPE- 
RATION. 

PILES have their origin in a varicose state 
of the veins of the inferior part of the rectum and 
verge of the anus. There are some natural cir- 
cumstances attending these vessels, which render 
them more liable than any other veins in the body 
to this disease : their trunks are within the cavity 
of the abdomen, and the inferior branches pass up 
between the lining of the intestine and the sphinc- 
ter muscle, to bring back the blood from the verge 
of the anus. From these circumstances, when 
the contents of the lower bowels are in a solid form, 
the veins are compressed between them and the 
muscle during the time of their expulsion ; and 
on the other hand, when the lower bowels are 
much irritated, as in diarrhoea or dysentery, attend- 
ed with tenesmus, although the contents are li- 
quid, the Action of the muscle is so violent as to 
compress the veins, and prevent the blood from 
passing freely through them. 

From these causes piles are first brought on, 
and afterwards gradually increased. 



ON VARICOSE VEINS. 291 

Piles are of two kinds, internal and external : 
the internal are those formed within the anus, and 
only protruded at the time of going to stool; the 
external, those that appear upon the verge of the 
anus, and never change their situation. 

The internal ones project inwards into the ca- 
vity of the gut, like berries, and, in general, are 
two or three in number, most commonly three; 
they are soft and loose in their texture in their 
easy state, but when inflamed are as turgid as a 
ripe grape, and when punctured, or when they 
burst, which sometimes happens, they bleed 
freely* 

In cases of long standing, they change their na- 
ture and appearance ; their contents coagulate and 
become solid, their coats increase in thickness, 
and they resemble pendulous excrescent tumors in 
other situations in the body. 

The internal piles are those which most gene- 
rally require the attention of the surgeon ; and 
when once they have acquired a certain size, are 
almost always attended by external ones as a con- 
sequent disease. There are, however, some in- 
stances of external piles where there are no inter- 
nal ones. 



292 THE EFFECTS OF LIGATURES 

The modes of removing this disease in either 
of these situations are essentially the same ; these 
are either cutting off the projecting portions, in 
which the convolutions of the veins are contained, 
by a sharp instrument, or tying them by a ligature, 
so tight as to produce mortification in the part, 
which afterwards drops off. 

The external piles very frequently have the 
blood coagulated in their cells, so that when they 
are cut off, the different coagula are seen project- 
ing some way from the membrane which sur- 
rounds them. 

The modes of treating the disease when within 
the reach of being cured, either by internal medi- 
cines or external application, is not immediately 
to our present purpose ; it is, however, highly 
proper that it should be mentioned in this place, 
that the disease does frequently admit of a consi- 
derable degree of palliation, and sometimes of a 
cure, by the internal use of Ward's paste, which 
has more power over these veins in making them 
contract, than any other medicine in general use. 

The spices in Ward's paste seem to act directly 
upon the hemorrhoidal vessels, as the balsam ca- 
pivi does upon those of the urethra. 



ON VARICOSE VEINS. 293 

Removing piles by a cutting instrument is at- 
tended with considerable pain, but this is of short 
duration, and is so much less severe than that 
which takes place in removing them by a ligature, 
that where it can be done with safety it is to be 
preferred. In this way external piles may always 
be removed, since the degree of induration of 
their coverings, produced by constant exposure 
to external circumstances, makes them less liable 
to bleed, and any haemorrhage that is brought on 
is within the reach of such applications as are ca- 
pable of stopping it : but this is by no means the 
case with internal piles ; their coats are thin, they 
are out of the reach of having styptic applications 
accurately and steadily applied to the bleeding ori- 
fice, and in some instances within my own know- 
ledge, where they have been removed by the 
knife, the bleeding has been so great as to endan- 
ger the patient's life. 

As external piies are most commonly the con* 
sequences of internal ones, and disappear when 
these are removed, it will never be proper to pro- 
pose any operation for external piles, till the inter- 
nal have been first destroyed, and a sufficient time 
has elapsed to ascertain that the others will not 
subside. 

Bb 2 



294 THE EFFECTS OF LIGATURES 

When internal piles have arrived at a consi- 
derable size, we are not warranted in cutting them 
off, on account of the bleeding, and have no other 
mode of removing them with safety but by means 
of the ligature. 

The common mode of tying piles is, by passing 
a needle armed with a double ligature through the 
basis of the pile, and tying one ligature on each 
side, so tight as to make the pile itself become 
turgid, and afterwards mortify. The pain attend- 
ing the immediate application of the ligature, and 
that which accompanies the inflammation it pro- 
duces, exceeds any thing met with in the most 
severe surgical operation. It is so great, that 
mam/ surgeons decline performing the operation ; 
and patients, however much they suffer from the 
disease, are for the most part deterred from hav- 
ing recourse to so violent a means of obtaining 
relief. 

The observations which have been made in the 
preceding part of this chapter upon tying veins 
appeared to me to apply to piles, as well as other 
veins in a varicose state ; and the great sufferings 
which patients experienced, whose piles had been 
tied, seemed to arise from the distended state of 
the veins, the delicate texture of whose coats 
could not bear so great a degree of extension, 



ON VARICOSE VEINS. 295 

without suffering from inflammation, by which the 
sensibility was so much increased as to produce 
the most agonising pain. 

This view of the subject led me to believe, 
that if the distension was prevented, by taking up 
the pile with a double ligature, and opening the 
intermediate portion of the enlarged veins, the 
pain would be less severe, and the operation ex- 
actly similar to that of taking up a vein in two 
places, and cutting through the portion between 
the ligatures, as has been already recommended, 
to prevent the inflammation extending itself along 
the vein. 

The principal objection which presented itself to 
this mode of tying piles was, the possibility of the 
part being withdrawn through the noose, by the 
natural actions of the intestine, as there was no 
increased bulk beyond the ligatures ; this, however, 
is not found to happen in practice. 

The first time this mode of performing the ope- 
ration was adopted, it was done in the following 
manner : the internal piles were made to protrude 
externally, so as to be exposed to view, and a nee- 
dle with a double ligature was passed through the 
centre of the basis of the pile, the needle was imme- 
diately cut off, and one of the ligatures was made 



296 THE EFFECTS OF LIGATURES 

to embrace one half of the pile, and then tied with 
a single knot, tolerably tight, so as to make that 
portion turgid ; the top of the pile was then remov- 
ed by the scissors, and the knot drawn as tight as 
possible, and then made secure by a second knot - 7 
the other portion of the pile was treated in 
the same way. Where there are several large 
piles, they are all to be secured in a similar man- 
ner^ after having their cavities laid open, and their 
contents evacuated ; the pain from the operation 
is by no means severe, it lasts for an hour or two, 
and then begins to subside, nor does it afterwards 
return with any degree of violence ; on the ninth 
day the ligatures are separated, and the patient 
finds himself free from complaint : upon examining 
the part, the whole of the piles are found to have 
been completely removed. The result of this 
operation was so favourable, as to encourage me 
to pursue the same mode of treatment in other 
cases, whenever they occurred to me. 

In four different instances, two of them in 
private practice, and two in St. George's hospital, 
the patients have been operated on in this way, 
and in all of them the symptoms have been unu- 
sually mild, and the cure completely effected. 

There is no better mode of giving an idea of 
the difference in violence of the symptoms in the 



ON VARICOSE VEINS. 297 

common mode of tying piles, and that which is 
here recommended, than by stating, that in the 
usual mode the patient suffers, in consequence of 
the operation, all the same symptoms as those of 
a violent attack of the piles, and these are kept up 
for five, six, or seven days, and in a very ag- 
gravated degree ; in the present mode, the symp- 
toms scarcely exceed those brought on by a 
moderate attack of piles, and do not continue with 
that degree of severity for more than a few hours, 
and then gradually subside. 

These four instances appear to me sufficient to 
show, that in this mode the piles can be completely 
removed, and that the symptoms are unusually 
mild. From what has been already stated upon 
the subject of tying veins in general, there could 
be no doubt of the advantages that would attend 
taking off the tension from the coats of the vein, 
and the only thing necessary to be known is, 
whether this can be done, and at the same time 
the pile be so secured as to answer the purpose 
of removing the disease ; the present facts ap- 
pear to establish this point, which is all that is ne- 
cessary to recommend the present mode of per- 
forming the operation. 



IP. la. '08 



